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Remittance Advice Tutorial - JF Part B

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Remittance Advice Tutorial

Medicare Remittance Advice
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). The amount being withheld or added in by the transaction for the FCN is always printed at the provider summary level. 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. 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. This field indicates the provider-level adjustment reason code. 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. 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. This field represents the total number of assigned claims reported on the remittance advice. This amount represents the sum of the PROVIDER ADJ DETAILS section on the remittance advice for the assigned claims. The total allowed amount represents the sum of CLAIM TOTALS: ALLOWED amounts for each assigned claim reported on the remittance advice. 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. 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. 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. This field represents the net paid amount for a given claim, including interest. The totals: number 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. 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. The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. 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%. 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. The allowed amount represents the Medicare reimbursement rate for the specific service billed. 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.) 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.' The total deductible amount is the sum of CLAIM TOTALS: DEDUCT amounts for each assigned claim reported on the remittance advice. 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. 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. 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. 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. The Medicare ID is obtained from Item 1a on the CMS-1500 claim form. The number of services is obtained from Item 24G on the CMS­1500 claim form. The total billed amount represents the sum of CLAIM TOTALS: BILLED amounts for each assigned claim reported on the remittance advice. 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. 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 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). 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. Totals Section The total coinsurance amount represents the sum of CLAIM TOTALS: COINS amounts for each assigned claim reported on the remittance advice. The place of service is obtained from Item 24B on the CMS-1500 claim form. 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. This field displays the total payment amount for claims before any provider adjustments are applied. 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. 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 Check/EFT number Remittance Advice date Number of pages included in Remittance Advice (RA) Remit Announcement 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.

Last Updated Tue, 29 Mar 2022 20:06:32 +0000