Remittance Advice and Financial advice and... · Remittance Advice – General ... Remittance Advice…

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  • Remittance Advice and Financial UpdatesPresented by EDS Provider Field Consultants

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    August 2007

  • October 2007Remittance Advice and Financial Updates

    Agenda

    Session Objectives Remittance Advice (RA) General Information The 835 Electronic RA Sections of the RA Codes (EOB, ARC & REMARK) Edits & Audits Review of RA Handout Accounts Receivable Other Provider Level Adjustments Primary Medical Provider (PMP) Administrative

    Payments Voiding Checks Electronic Funds Transfers (EFT)

  • October 2007Remittance Advice and Financial Updates

    Session Objectives

    Learn how to read and understand the weekly Remittance Advice (RA)

    Determine why claims deny or suspend

    Use your RA and Web interChange to follow up on claims

    Understand the 835 Transaction

    Realize the benefits of electronic funds transfers (EFT)

    Understand financial transactions; refunds, accounts receivables (AR), claim specific and non-specific transactions

    Understand EOB, ARC and REMARK codes

    Understand how the EDS system applies edits and audits to properly adjudicate claims

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice General Information

    The most significant tool the IHCP provider has to monitor participation in the program is the weekly Remittance Advice (RA)

    The RA provides information about claims processing and financial activity

    The Web interChange Claim Inquiry/Show More Claim Information functions provide similar information on an individual claim basis

    The HIPAA 835-Health Care Claim Payment Advice is the electronic version of the RA

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice General Information

    Providers receive a weekly RA along with their check. Providers enrolled in electronic funds transfer (EFT) receive a copy of their check

    Providers who wish to receive RA information electronically (HIPAA 835 transaction) must contract with an approved vendor who has completed the trading partner profile and agreement

    The IHCP 835 Transaction Companion Guide is available at www.indianamedicaid.com, and the Web interChange HELP function

    http://www.indianamedicaid.com/

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice General Information RAs provide information about adjudicated claims

    that are paid, denied and adjusted

    Paper RAs also include information on claims in process, and claims that generate claim correction forms (CCF)

    CCFs are mailed with the paper RA, along with the weekly Banner Pages

    Paper RAs, CCFs and Banner Pages are also sent to providers receiving electronic (835) RAs

    Banner Pages are intended to keep providers abreast of the most recent developments in the IHCP program

    The RA outlines claim information at the HEADER (claim level) and the DETAIL (service line level)

    Each section of the RA, such as Claims Paid or Claims Denied, totals the information at the end of that section

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice Section Descriptions

    Claims Paid- This section shows claims with a paid status, including claims paid at zero

    Claims Denied- This section shows detailed information for denied claims

    Claims in Process- This section lists claims in the processing cycle that have not yet been finalized, such as the following:

    Claims that have generated CCFs

    Claims that have attachments

    Claims that are past filing limit

    Claims that require manual pricing

    Voids and Replacements that have not finalized

    Suspended Claims

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice Section Descriptions

    Claims in Process (continued)- Claims in process will ultimately be shown as

    paid, denied or adjusted on a subsequent RA

    Claims in suspense only appear in the RA for the week in which they first suspend, until they are paid or denied

    Note: The RA will repeat each section for each claim type (for example: inpatient, outpatient, crossover, home health, and so forth).

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice Section Descriptions

    Claim Void/Replacements- This section lists claims that have been voided or replaced. Each adjusted claim will show two header internal control number (ICN) lines: The first header line is for the original claim (mother

    claim) The second header line is for the replacement claim

    (daughter claim) If a claim is voided or replaced in the same financial

    cycle as the original claim, the original claim will appear in the denied claim section, and the void/replacement will show in the void/replacement section

    Financial Transactions- This section lists the provider level adjustments, which include non-claim specific payouts, refunds, and accounts receivable (AR) transactions

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice Section Descriptions

    EOB Code Descriptions- This section lists Explanation of Benefit (EOB) codes applied to submitted claims, along with the respective narratives that explain why the claim suspended, denied, or did not pay in full

    ARC Code Descriptions- This section lists Adjustment Reason Codes (ARC) along with respective code narratives that reflect the adjustments in payment between billed amounts and allowed or payment amounts

    The narratives for EOB and ARC codes are listed at the end of the RA

  • October 2007Remittance Advice and Financial Updates

    Remittance Advice-Section Descriptions

    Summary - This page summarizes all claim and financial activity for each weekly cycle, and gives year-to-date totals

    Summary Page Sub-sections Claims Data

    This sub-section contains current and year-to-date totals for claims paid, claims adjusted, interest, claims denied and in process

    Earnings Data This sub-section contains current and year-to-date totals

    for claim payments, managed care administrative payments, Hoosier Healthwise capitation payments, system payouts, and accounts receivable

    Earnings data also includes current and year-to-date information on refunds and other financial transactions

    Payments to Lien Holders This sub-section contains current and year-to-date totals

    for payments to lien holders, if applicable

  • October 2007Remittance Advice and Financial Updates

    Explanation of Benefit Codes

    The EOB code is a four-digit number

    EOB codes are listed at the HEADER and DETAIL levels immediately following the claim information:000 lists codes that pertain to the header; 001

    lists codes that pertain to detail line one; 002 lists codes that pertain to detail line two, and so forth

    EOB code definitions are located at www.indianamedicaid.com; Provider Services; EOB Descriptions

    EOB codes are considered local codes and are not transmitted in the electronic 835 transaction

    http://www.indianamedicaid.com/

  • October 2007Remittance Advice and Financial Updates

    EOB Examples

    Code Description Provider Action Required

    0203 Recipient ID number is missing

    Resubmit claim with 12-digit member identification number (RID)

    4033 The modifier used is not compatible with the procedure code billed

    Refer to Current Procedural Terminology (CPT) code manual and resubmit claim with correct modifier

  • October 2007Remittance Advice and Financial Updates

    Adjustment Reason Codes (ARCs)

    A complete list of ARCs is available on the Washington Publishing Company Web site: www.wpc-edi.com/codes/

    ARCs are alpha-numeric codes from an external national code set used with the 835 transaction

    ARCs are reported at HEADER and DETAIL levels immediately following claim information

    Most claims on the RA also include Adjustment Remark Codes

    http://www.wpc-edi.com/codes/

  • October 2007Remittance Advice and Financial Updates

    Remark Codes (REMARKS)

    Remark Codes are provided as clarification in conjunction with the Adjustment Reason Codes

    Remark Codes are also available at www.wpc-edi.com/codes/

    Remark Codes are alpha-numeric, and reported at the HEADER and DETAIL levels immediately following the claim information

    ARC and REMARK codes are national codes required for use with HIPAA compliant transactions

    http://www.wpc-edi.com/codes/http://www.wpc-edi.com/codes/

  • October 2007Remittance Advice and Financial Updates

    EOBs / ARCs / REMARKS Examples

    EOB ARC Remark

    0203 Recipient I.D. number is missing-Please provide and resubmit

    16-Claim or service lacks information that is needed for adjudication.

    M58-Please resubmit the claim with the missing or correct information so that it may be processed

    2014-Personal resources collected does not agree with amount reported by county office. Liability amount deducted from your claim was based on the amount reported by the county office

    142-Claim adjusted by the monthly Medicaid patient liability amount

    N58-Patient liability amount missing, invalid, or not on file

  • October 2007Remittance Advice and Financial Updates

    Edits, Audits and the EOB

    Edits - are designed to verify data submitted on the claim form and ensure claims are submitted with the necessary data to process the claim

    Audits - are designed to compare the claim being processed to the claims that have already been paid (paid history)

    Edits and Audits are designed to ensure claims are paid within policies