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New Provider Staff Webinar Medicare Remittance Advice Palmetto GBA - March 2009 1 Objectives • Introduce the Medicare Remittance Advice • Define the purpose of the Medicare Remittance Advice • Identify the layout of the Medicare Remittance Advice • Demo the Medicare Remit Easy Print software • Provide resources for the Medicare Remittance Advice Palmetto GBA - March 2009 2 What is an RA? • A notice of payments and adjustments • May accompany a payment or a denial – Includes reasons for payments and adjustments • Used to post claim details • Review claim adjustments Palmetto GBA - March 2009 3 Types of RAs • RA transmitted in an electronic format – Electronic Remittance Advice (ERA) • RA in a paper format – Standard Paper Remittance (SPR) Advice • Information on ERA and SPR is similar • ERA offers data and administrative efficiencies not available in an SPR Palmetto GBA - March 2009 4 Why receive the ERA? • There are several advantages to receiving the ERA – Faster communication and payment notification – Faster account reconciliation through electronic posting – Automation of follow-up action – Paperwork reduction – Detailed information – Access to data in a variety of formats – FREE Medicare-supported software • Medicare Remit Easy Print (MREP) software Palmetto GBA - March 2009 5 The Purpose of the RA • Provide detailed payment information on health care claims • Describe why original charges not fully paid • Help to direct provider’s next steps – Resubmit rejected claims – Submit claim to secondary payers – File an appeal – Bill the patient Palmetto GBA - March 2009 6 The Codes on an RA • Medical or Non-medical Code Sets – Medical Codes • The codes submitted on claims – HCPCS and CPT codes – Non-medical Codes • Codes describing why claims were denied or adjusted – – – – Group Codes Claim Adjustment Remark Codes (CARCs) Remittance Advice Remark Codes (RARCs) Provider-Level Adjustment Reason Codes Palmetto GBA - March 2009 7 Group Codes • Always shown with a reason code – Indicates when a provider may or may not bill a patient for the non-paid balance of services furnished Code Description CO Contractual Obligation – Provider is not permitted to bill the patient for the amount of adjustment CR Correction and Reversal – Change to a previously processed claim OA Other Adjustment – used when no other Group Code applies PR Patient Responsibility – includes deductible and co-insurance Palmetto GBA - March 2009 8 Claim Adjustment Reason Codes (CARCs) • Provide financial information about claim decisions – The numeric code will appear after the group code Code Financial Information 1 Deductible amount 2 Co-insurance amount 3 Co-payment amount 4 Invalid procedure code/modifier combination or missing modifier 5 Procedure codes inconsistent with place of service 40 Charges do not meet requirement of emergent/urgent care 96 Non-covered charges Palmetto GBA - March 2009 9 Remittance Advice Remark Codes (RARCs) • Used in conjunction with CARCs – Further explains an adjustment or to indicate if and what appeal rights apply – Some used to relay informational messages Code Informational Message M1 X-ray not taken within last 12 months M2 Not paid separately with the patient is an inpatient M3 Equipment is the same/similar to equipment already being used M4 Alert: This is the last payment for this DME N1 Alert: You may appeal this in writing within the required time limit N24 Missing/incomplete/invalid EFT banking information Palmetto GBA - March 2009 10 Provider-Level Adjustment Reason Codes • Used for adjustments not related to specific claims or services Code Description 50 Late Charge – used to identify late claim filing penalty 51 Interest Penalty Charge – identifies interest assessment for late filing IR Internal Revenue Service Withholding – used for IRS withholdings Palmetto GBA - March 2009 11 Components of the SPR • Professional (Part B) SPRs are split into three sections – Header (section 1) – Assigned / Unassigned claims (section 2) – Glossary (section 3) Palmetto GBA - March 2009 12 CPT codes, descriptors and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Palmetto GBA - March 2009 13 Palmetto GBA - March 2009 14 Balancing a Professional RA • Balancing requires that: – the total paid is equal to the total billed • plus or minus any payment adjustments • According to HIPAA – Every electronic transaction issued must balance at the: • Service-line level • Claim level • Transaction level Palmetto GBA - March 2009 15 Balancing a Professional RA Service-Line Level Dollar Amount Field Description 10.00 BILLED Total submitted charge for this line service - 5.63 AMT A service-line level adjustment explained by Group Code and CARC PROV PD Paid amount for this service line 4.37 CPT codes, descriptors and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Palmetto GBA - March 2009 16 Balancing a Professional RA Claim Level Dollar Amount Field Description 66.00 BILLED Total submitted charge on claim - 9.97 COINS A claim-level adjustment due to coinsurance amount - 16.17 AMT A claim-level adjustment explained by the Group Code and CARC PROV PD Paid amount for this claim 39.86 CPT codes, descriptors and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Palmetto GBA - March 2009 17 Balancing a Professional RA Transaction Level Dollar Amount Field Description 161.25 PROV PD AMT Total of claim payment amounts - 25.44 PROV ADJ AMT Total provider-level adjustments 135.81 CHECK AMT Check / EFT amount Palmetto GBA - March 2009 18 Medicare Remit Easy Print • Saves time and money • Generates special reports • Prints information for use by other payers • Easy to navigate and review remit information • Allows quick and easy access to claim information Palmetto GBA - March 2009 19 Resources *Washington Publishing Company http://www.wpc-edi.com *Palmetto GBA http://www.PalmettoGBA.com *Centers for Medicare & Medicaid Services (CMS) – Understanding the Remittance Advice http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf Palmetto GBA - March 2009 20 Thank you for attending! Please complete the evaluation immediately following the Q&A session