SPR Field Descriptions - JE Part B
Standard Paper Remittance (SPR) Advice Field Descriptions
Medicare Administrative Contractor (MAC) and Provider Identification Section
The first page of a paper remittance advice is identified with a statement, "MEDICARE REMITTANCE ADVICE" and contains complete information on the carrier and billing information for the provider, as follows:
- Medicare Carrier/MAC identification and complete address
- Medicare Carrier/MAC Provider Call Center telephone number
- Provider's name and billing address
- Provider's Medicare National Provider Identifier (NPI) #
- Number of pages included in Remittance Advice (RA)
- Remittance Advice date
- Check/EFT number (#)
Note: If a remittance advice contains multiple pages, the subsequent pages will contain abbreviated carrier and provider information, which excludes the mailing and telephone information.
Remit Announcement Section
Medicare related messages, reminders and other urgent and/or important information are displayed at the beginning of the paper remittance advice in an asterisk (*) segmented box.
Standard Paper Remit (SPR) Field Headings and Descriptions
Abbreviations must be used in the claim and detail information to maximize the amount of the data that can reasonably and legibly be printed across the page. In most cases, the abbreviations should be self-explanatory. Each field found in this section is discussed as follows:
|PERF PROV||The performing provider obtained from either Item 24J (if a provider within a group) or 33 (if a sole provider) on the CMS-1500 claim form.|
|SERV DATE||The dates of service are printed under the "SERV DATE" column. The "date of service from" and the "date of service through" are obtained from Item 24A on the CMS-1500 claim form.|
|POS||The place of service is obtained from Item 24B on the CMS-1500 claim form.|
|NOS||The number of services is obtained from Item 24G on the CMS1500 claim form.|
|PROC||The HCPCS/CPT procedure code is obtained from Item 24D on the CMS-1500 claim form. When Medicare changes a procedure code while processing a claim, the procedure code under which the service was paid is displayed in the PROC field, followed by modifier CC (Code Change). The procedure that had originally been submitted is entered in parentheses directly under the paid procedure code. This situation will occur when a procedure is down-coded.|
|MODS||The HCPCS/CPT modifiers are printed under the "MODS" column. Up to four modifiers will be printed. The modifier(s) reported in Item 24D on the CMS-1500 claim form or those added by Noridian for pricing reduction (i.e., 51) or as notification of a change to the submitted procedure will be displayed.|
|BILLED||The billed amount for an individual service taken from each claim line in Item 24F on the CMS-1500 claim form is displayed in this field.|
|ALLOWED||The allowed amount represents the Medicare reimbursement rate for the specific service billed.|
|DEDUCT||This field displays the amount of any deductible applied to the claim. The patient is responsible for this amount. If an amount is displayed in this field, this is the amount that the beneficiary (or other insurer, if applicable) is responsible for paying the provider. NOTE: Deductible amounts are subject to change annually.|
|COINS||The coinsurance amount represents the amount for a service for which the patient is responsible. For Medicare Part B, the coinsurance amount is generally 20% of the allowed amount. If an amount is displayed in this field, this is the amount that the beneficiary (or other insurer, if applicable) is responsible for paying the provider. NOTE: Coinsurance amounts are subject to change annually. The coinsurance for most outpatient mental health care is 50%.|
|GRP/RC-AMT||Reason codes (RC) and amount of adjustments are printed under the "GRP/RC-AMT" column. Under the standard format, only the claim adjustment reason codes approved by the American National Standards Institute (ANSI) X12 835 Insurance Subcommittee are printed under the "GRP/RC-AMT" column. Group (GRP) Values: (1) PR - Patient Responsibility: This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary's behalf. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code. (2) CO - Contractual Obligation: This includes any amounts for which the provider is financially liable, such as participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties or medical necessity denials/reductions. The patient may not be billed for these amounts (3) OA - Other adjustment: This would only be used if neither PR nor CO applied. This field will be used when a different insurance is primary to Medicare. (4) CR - Correction to or Reversal of a prior decision: This applies whenever there is a change to a previously adjudicated claim. CR explains the reason for the correction. Example: GRP/RC-AMT "CO-16" Claim/service lacks information which is needed for adjudication. REM M81 "Patient's diagnosis code(s) is truncated, incorrect, or missing: you are required to code to the highest level of specificity." A group code is always accompanied by a reason code and an amount, even if that amount is zero. Likewise, a reason code is always accompanied by a group code and an amount.|
|PROV PD||The actual amount paid to the provider is printed under the "PROV PD" column. This amount DOES NOT include any amounts in the PREV PD, INT or LATE FILING CHARGE fields in the Provider Adjustments (ADJ) Details Section.|
|NAME||The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form.|
|MID||The Medicare ID is obtained from Item 1a on the CMS-1500 claim form.|
|ACNT||If a provider supplies the patient account number used within their office on Item 26 on the CMS-1500 claim form, Medicare will print this number, up to 20 characters, in the ACNT field to assist provider staff with identifying their patient. A zero appears if no internal number is submitted with the claim.|
|ICN||The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. The first two digits of the Internal Control Number that appear on your payment listing will show the type of claim or claim adjustment. The next two digits of the ICN will show the two-digit year the claim was received or the adjustment was initiated. The remaining digits are a sequential number, assigned to each claim on the Julian date, in numeric order.|
|ASG||This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form. NOTE: Medicare will change the assignment in certain situations, regardless of what had been reported on the claim. When a provider submits certain services as unassigned that can only be billed as assigned, the claims processing system changes the assignment from unassigned to ASSIGNED and an informational message (CO-111) is displayed. If the claim consists of one service that must be billed as assigned and the other services can continue to be billed as unassigned, Noridian will manually divide, or split, the claim. This allows for appropriate unassigned services to continue processing while a second claim is created for the services that require assignment.|
|MOA||Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. A maximum of five Medicare outpatient adjudication (MOA) remarks code(s) per ICN are printed in the MOA field. (Codes listed on each claim line in the MOA section will be defined in the Glossary at the end of the RA.) Under the standard format, only the MOA codes approved by CMS are used. A complete list of remark codes is available. Select "Remittance Advice Remark Codes" from the "HIPAA-Related Code Lists" page. Examples: MA01 "If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late." MA115 "Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA)."|
|REM||Applicable remark codes are printed in the REM field. Under the standard format, only the remark codes approved by CMS are printed in this field. There is a limit of five remark code entries for a given ICN on a standard paper remittance advice. A complete list of remark codes is available. Select "Remittance Advice Remark Codes" from the "HIPAA-Related Code Lists" page.|
|PT RESP||Patient Responsibility (PT RESP) represents the full amount for which the beneficiary or their secondary insurer can be held liable for payment by the provider. All denials or reductions from the provider's billed amount (positive and negative RCAMT entries) with a group code of PR (patient responsibility), including the deductible and coinsurance, are totaled in the PT RESP field at the end of each claim. The patient responsibility is obtained through the following calculation:
PT RESP = DEDUCT + COINS + RC-AMTs signified by group code PR
|The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claims totals, for each column heading respectively.|
|GRP/RC AMT||The total claim GRP/RC Amount is represented with the exception of the following (for balancing purposes) (a) any amount that has a group code = CR (b) previous paid amount: OA-B13. A complete list of remark codes is available.|
|PROV PD||The total provider paid amount represents the total provider paid amount for all services on the claim.|
|PREV PD||When a claim has been adjusted, the dollar amount previously paid to the provider for services on the original claim is reflected in this field.|
|ADJS||When a claim has been adjusted, the dollar amount previously paid to the provider for services on the original claim is reflected in this field|
|INT||The interest field represents the amount of interest paid on the original claim. This difference between the current interest on the adjustment claim and the previous interest from the original claim is displayed in this field. CMS requires Medicare to pay interest on claims submitted with complete information when not paid by the 30th day after the date of receipt. Interest is not required on claims requiring external investigation or development, claims for which no payment is due or claims which are full denials. The Treasury Department determines the rate of interest. The total interest amount reported on the remittance advice represents all claim level interest amounts. This amount can be either a positive or negative value. If the previous interest is more than the current interest, then this field will be a positive number. If the previous interest is less than the current interest, then this field will be a negative number. The signed amount (whether it is positive or negative) is based on the difference between the current interest and the previous interest.|
|LATE FILING CHARGE||The total late filing amount reported on the remittance advice is an accumulation of the late filing amounts from each line of the claim. This amount can be either a positive or negative value. If the previous late filing is more than the current late filing, then this field will be a negative number. If the previous late filing is less than the current late filing, then this field will be a positive number. Claims must be filed no later than the end of the calendar year following the year in which the services were provided. However, the filing limit is extended another full year if the service was provided during the last three months of the year. For Medicare assigned claims filed more than one year from the service date, payment will be reduced by 10%. This 10% reduction cannot be billed to the patient.|
|CLAIM INFORMATION FORWARDED TO||When claim information is forwarded to the patient's supplemental insurer, the name of that other payer or carrier to whom the data was sent is displayed. If the beneficiary has multiple crossover companies only one will print in this section. The following MOA message accompanies claims that have been forwarded to a supplemental insurer: "MA18: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them."
Note: Although MOA message MA18 appears on claims forwarded to MEDIGAP companies, the name of a MEDIGAP insurer to whom data has been forwarded is not printed in this section. Providers can locate the MEDIGAP insurer by researching the data submitted in Items 9 through 9d on the CMS-1500 claim form.
|NET||This field represents the net paid amount for a given claim, including interest.|
Totals Summary Section
To help providers balance their billed amounts against the Medicare payments and adjustments, paid and adjusted amounts are totaled at the end of the assigned claims listing.
|# OF CLAIMS||This field represents the total number of assigned claims reported on the remittance advice.|
|BILLED AMT||The total billed amount represents the sum of CLAIM TOTALS: BILLED amounts for each assigned claim reported on the remittance advice.|
|ALLOWED AMT||The total allowed amount represents the sum of CLAIM TOTALS: ALLOWED amounts for each assigned claim reported on the remittance advice.|
|DEDUCT AMT||The total deductible amount is the sum of CLAIM TOTALS: DEDUCT amounts for each assigned claim reported on the remittance advice.|
|COINS AMT||The total coinsurance amount represents the sum of CLAIM TOTALS: COINS amounts for each assigned claim reported on the remittance advice.|
|TOTAL RC AMT||This field indicates the total amount of adjustments made to assigned claims due to Claim Adjustment Reason Codes (CARCs) listed on each service line. This excludes interest, late filing charges, deductibles, and amounts previously paid for rendered services.|
|PROV PD AMT||This field displays the total payment amount for claims before any provider adjustments are applied.|
|PROV ADJ AMT||This amount represents the sum of the PROVIDER ADJ DETAILS section on the remittance advice for the assigned claims.|
|CHECK AMT||The check amount is system calculated. This field will always display $0.00 on duplicate provider remittance advices (even when the original remit showed a payment amount).|
Provider Adjustment (ADJ) Details Section
Offsets to payments, perhaps for a prior Medicare overpayment, are shown as an adjustment to the provider's payment at the summary level, rather than as an adjustment at an individual claim level in the remittance advice. The provider adjustment reason codes are as follows:
PLB REASON CODE - This field indicates the provider-level adjustment reason code.
|50||Net of all late file charges (positive and negative) of all the impacted claims on the remittance advice. Used to identify Late Claim Filing Penalty.|
|72||Refund - lump sum invoice amount from manual invoices|
|AP||Used to reflect accelerated payment amounts or withholdings. A positive value represents a withholding. A negative value represents a payment.|
|B2||Refund - Used to reflect accelerated payment amounts or withholdings. A positive value represents a withholding. A negative value represents a payment.|
|BN||Incentive Bonus Payment - indicates that an Electronic Health Record (EHR) Demonstration, Health Professional Shortage Area (HPSA), HPSA Surgical Incentive Payment (HSIP), or Primary Care Incentive Payment (PCIP) program payment was made|
|C5||Manual Invoice Payments|
|CS||Adjustment - Used to provide supporting identification. Code "RI" is used on a Professional RA for a Reissued Check Amount (e.g., CS/RI).|
|E3||Accounts payable debit memo withholding amount|
|FB||Forwarding Balance - When an account receivable is created, it is tied to an ICN. The FCN field will reflect the ICN that corresponds to the account payable record or overpayment. The FB code is informational; it tells a provider that no funds were taken but an adjustment has been completed. The main reasons for an FB remittance code are:
|IR||Internal Revenue Service Withholding - Used for Internal Revenue Service withholdings.|
|L3||Provider Penalty - indicates an amount withheld from payment based on an established penalty|
|L6||Interest owed: - If the net interest is added to the "TOTAL PROV PD" amount, then the offset detail will be a negative number. If it is subtracted from the "TOTAL PROV PD" amount, then the offset detail will be a positive number.|
Levy - Used for IRS levy
Note: Provide your TIN when speaking with IRS or Treasury. Funds could be offset from Medicare due to other federal debts owed
|WO||Withholding - An offset was done as a result of a previous overpayment (A/R accounts receivable). The WO indicates Medicare has deducted funds from the remit to satisfy an overpayment. A reference number (the original ICN and Medicare ID) is applied for tracking purposes. The FB remittance code will be sent first to notify of the adjustment, and a WO remittance will be sent second to notify of the offset of funds.|
Levy - Used for Federal Payment Levy Program
Note: Provide your TIN when speaking with IRS or Treasury. Funds could be offset from Medicare due to other federal debts owed
|AP/ B2||If the financial transaction is tied to an ICN, the ICN will be plugged in the FCN field. If the financial transaction is NOT tied to an ICN, the CCN will be plugged in the FCN field.|
FCN - The Financial Control Numbers (FCNs) enable the provider to associate the offset with those claims and payments that led to the withholding. This field indicates the Financial Control Number (FCN) that this adjustment relates to when the adjustment refers to a claim that appeared on a previous SPR. This usually matches the ICN field of the previous claim. If the adjustment in question does not relate to a specific claim, this field is blank.
|AG||An Aggregate account number will appear in the FCN field when a WO occurs (example: 123456AG). Aggregate means there are at least two or more overpayments for less than the Medicare under-tolerance amount of $25. Each month, Medicare checks to see if two or more overpayments of the same type reach the $25 limit. If the amount is met, one overpayment letter is sent with the patient information for each account. Duplicates of the initial demand letter may be requested from the Recoupment Department.|
A single Medicare ID is printed if the offset is for a Medicare overpayment and an Medicare ID is associated with the offset. The Medicare ID will not be supplied if none is associated with the offset. Multiple Medicare IDs are not printed in this field, as the paper remittance advice must be consistent with the electronic remittance advice standard that only permits a single Medicare ID in this field.
|WO||If the A/R CCN is tied to an ICN, the Medicare ID from the ICN will print. If the A/R CCN is NOT tied to an ICN, the Medicare ID will correspond to the Medicare ID entered during setup of the A/R. If the Medicare ID is not entered during setup, the Medicare ID field will be blank.|
|AP/B2||If the financial transaction is tied to an ICN, the Medicare ID from the ICN will print. If the financial transaction is not tied to an ICN, the Medicare ID will be blank.|
|L6/J1/50||Will always be blank as Medicare ID information is not applicable for these types.|
|FB||Will be the Medicare ID associated with the ICN that corresponds to the account payable record or overpayment.|
The amount being withheld or added in by the transaction for the FCN is always printed at the provider summary level.
|WO||The amount that the provider's payment was offset as a result of a previous overpayment (A/R).|
|AP||The amount of the advance payment. This amount is a positive adjustment vs. an offset/negative adjustment to the provider's payment, thus the amount is shown as a negative under the AMOUNT column.|
|B2||The amount of the refund. This amount is a positive adjustment vs. an offset/negative adjustment to the provider's payment, thus the amount is shown as a negative under the AMOUNT column.|
|L6||The amount of CPT interest accrued. This amount is a positive adjustment vs. an offset/negative adjustment to the provider's payment, thus the amount is shown as a negative under the AMOUNT column.|
|50||The amount associated with any late filing penalties assessed against the provider's payment.|
|FB||When payment less than $1.00 are withheld on a paper remittance advice, the amount being withheld is printed under the AMOUNT column. When reporting the issuance of the withheld amount in a later paper remittance advice, the amount being paid out is shown as a negative amount for balancing purposes under the AMOUNT column. For full claim adjustments that are overpayments, this amount represents an amount that was overpaid on a previous claim. The adjustment detail amount will be a negative amount and the FCN will contain the original ICN and the Medicare ID for the overpayment.|
Accounts Payable Section
Accounts payable are represented by reason codes FB and BF under the Provider ADJ Details segment.
To report issuance of the withheld amount in a later paper remittance advice, accounts payable information is again included in the Provider ADJ Details segment and represented with a negative sign as this would be monies added onto the providers payment. The service level adjustments are not repeated, nor is MA22 used for the payout of an account payable record.
Summary of Non-Assigned Claims Section
If a remittance advice contains both assigned and non-assigned claims, information on any non-assigned claims will be listed separately after the assigned claims to avoid any inadvertent use of non-assigned claims information, for which Medicare payment is not issued to a provider, to balance accounts.
Claim listings included in the remittance advice are printed in the following order:
- In the assigned claims section, pay claims appear first followed by non-pay claims. Since all non-assigned claims to providers are non-pay claims, they will appear in alphabetical order by the beneficiary's last name.
- Multiple claims having the same beneficiary name will appear in ICN order.
The standard remittance advice format and messages provide all data in the beneficiary Medicare Summary Notice (MSN), except for any interest paid to the beneficiary. Fields contained in the summary of non-assigned claims sections are identical to the fields contained in the assigned claim and detail information section. Therefore, only information, which pertains to non-assigned claims, is discussed below:
|ASG||This field contains a value of N (no) for all non-assigned claims.|
|MOA||MOA remark code MA28 is printed in the MOA field for every non-assigned claim in addition to any other applicable MOA codes. MA28:Receipt of this notice by a physician who did not accept assignment is for information only and does not make the physician a party to the determination. No additional rights to appeal this decision, above those already provided for by regulation/instruction, are conferred by receipt of this notice.|
|RC-AMT||Non-assigned claims in excess of 115% of the Medicare physician fee schedule or reasonable charge amount will display reason code CO-45. The reduction representing the difference between the limiting charge and the allowed amount will be shown with group and reason code PR-42 for non-assigned claims.|
|PROV PD||$0.00 is printed in the PROV PD column for non-assigned claims.|
|PT RESP||As the patient, or any secondary insurer, is liable for the entire amount of the claim when limitation of liability does not apply, not to exceed 115% of the Medicare fee schedule or the reasonable charge, the full amount of the bill up to the limiting charge cap is entered in the PT RESP field for a non-assigned claim. If limitation of liability does apply, and the beneficiary did not sign an Advanced Beneficiary Notice (ABN), the waiver to assume financial responsibility, the amount of the denied services is excluded from the total in the PT RESP field. If limitation of liability does apply and the beneficiary signed an ABN, the full amount of the bill up to the limiting charge cap, is entered in the PT RESP field for the non-assigned claim. Denial amounts subject to limitation of liability (for which the beneficiary did not sign a waiver to assume financial responsibility) and reduction amounts in excess of 115% of the Medicare fee schedule or the reasonable charge are shown with a group code of 'CO.' PT RESP = BILLED - RC-AMTs signified with group code CO.|
|INT||Interest payments to beneficiaries are not shown on a provider's remittance advice, just as interest to a provider is not shown on a beneficiary's Medicare Summary Notice. Therefore, the INT field under the SUMMARY OF NONASSIGNED CLAIMS section in the standard provider remittance advice will always contain 0.00 for non-assigned claims, regardless of whether or not the payment accrued interest. Beyond that, all (non-bulletin) payment information on an MSN agrees with that on the remittance advice for the same claim.|
|AMOUNT PAID TO BENEFICIARY||The amount paid to the beneficiary will display as OA-100 in the GRP/RC-AMT field. For adjustments, this amount will include the amount paid to the beneficiary on the base and adjusted claim.|
|NON-ASSIGNED CLAIM/NON-PARTICIPATING PHYSICIAN BILLING FOR MORE THAN 115% OF LIMITING CHARGE||The amounts a provider may and may not bill a beneficiary must be expressed on a remittance advice through use of group codes and 835 adjustment reason codes. Reason code 45, charges exceed your contracted/legislated fee arrangement, is used when a non-participating physician has billed for more than 115% of the limiting charge. The physician must refund any amount already collected from the beneficiary or a representative in excess of the amount shown in the total Patient Responsibility field.|
The remark and/or reason code that appears in the Claim Detail Information Section of the remittance advice has the associated message description printed in the Glossary Section to facilitate interpretation.
Codes and related message descriptions are printed in the following order:
- Group codes
- Reason codes
- Line level remark codes
- Claim level remark codes/MOA
- Claim and detail level remark codes
- Adjustment codes
|GROUP CODE||Each group code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same group code appears multiple times, it will be printed only once.|
|GROUP CODE MESSAGE||The message for each group code is defined by CMS and displays on the remittance advice as applicable.|
|REASON CODE||Each reason code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same reason code appears multiple times, it will be printed only once.|
|REASON CODE MESSAGE||The message for the reason code is listed under this section.|
|REMARK CODE||Each remark code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same remark code appears multiple times, it will be printed only once.|
|REMARK CODE MESSAGE||The message for the remark code is listed under this section.|
|MOA CODES||Each MOA code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same MOA code appears multiple times, it will be printed only once.|
|MOA CODE MESSAGE||The message for the MOA code is listed under this section.|
|ADJUSTMENT CODE||Each adjustment code appearing in the Provider Adjustment (ADJ) Details Section of the remittance advice is listed under this section. If the same offset code appears multiple times, it will be printed only once.|
|ADJUSTMENT CODE MESSAGE||The message for each adjustment code is defined by CMS and displays on the remittance advice when applicable.|
Duplicate Remittance Advice
If a provider has a need for a duplicate remittance advice, they may request one on an individual claim basis or for all the claims associated with one check. The upper right hand corner statement on a duplicate remittance advice is modified to read, "Medicare Duplicate Notice." The CHECK AMT on a duplicate remittance advice will always read $0.00 (even when the original remit showed a payment amount).
If a duplicate remittance advice is requested for a single check, the date shown on the remittance advice will be the date the original remittance advice was printed. However, if multiple remittance advices are requested, they will be mailed together and the original date of the remittance advice will not display. In this situation, the date in which the duplicate remittance advices were produced will display.
The date shown on the remittance advice for a single claim will be the date of the original remittance advice. However, if a provider requests duplicate remittance advices for multiple claims, the date in which the duplicate remittance advices are produced will display.
Psychiatric Reduction Claims
Amounts on the MSN and the remittance advice must agree. To this end, payment reductions such as the 37.5% psychiatric reduction is calculated and rounded at the line level, not the claim level. In addition, a psychiatric reduction is always expressed with ANSI X12 835 reason code 122. A psychiatric reduction is never listed as an otherwise non-covered charge or the claim may be rejected by the patient's supplemental insurer.
Last Updated Fri, 09 Dec 2022 16:01:59 +0000