Part A Medicare Remittance Advice 5/6/2014 May 6, 2014 Presented by: Provider Outreach and Education This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 2 1 Part A Medicare Remittance Advice 5/6/2014 Notice of payments and adjustments sent to providers, billers and suppliers. The RA explains the reimbursement decisions including the reasons for payments and adjustments of processed claims 3 Claim is received and accepted Claim is processed and payment is determined Cahaba GBA generates the RA and sends to the provider RAs may be created in two formats: Standard Paper Remittance Advice (SPR) Electronic Remittance Advice (ERA) Information on the SPR and ERA are similar 4 2 Part A Medicare Remittance Advice 5/6/2014 Denied claim Zero payment Partial payment Reduced payment Penalty applied Additional payment Supplemental payment 5 Medical code sets HCPCS and CPT codes Non-medical code sets Group Codes Claim Adjustment Reason Codes (CARCs) Remittance Advice Remark Codes (RARCs) Provider – Level Adjustment Reason Codes (PLB) 6 3 Part A Medicare Remittance Advice 5/6/2014 Group codes CO – Contractual agreement between Medicare and the provider CR – Correction to a prior claim. Not allowed in 5010 format OA – Use when no other Group Code applies PR – Adjustment amount billed to the beneficiary or insured CARCs – updated three times per year www.wpc-edi.com/codes 1 – Deductible amount 2 – Coinsurance amount 3 – Co-payment amount 96 – Non-covered charges 7 RARCs – updated three times per year www.wpc-edi.com/codes M1 – X-ray not taken within past 12 months M2 – Not paid separately when patient is inpatient N24 – Electronic funds transfer (EFT) banking information missing/incomplete/invalid PLB Reason Codes 50 – Late charge FB – Forwarding Balance FB/BF – Negative Values FB/CO – Positive Values WO/OR – Overpayment Recovery 8 4 Part A Medicare Remittance Advice 5/6/2014 Reading an Institutional SPR 9 Institutional SPRs are split into two sections: All Claims (AC) Page(s) - detailed information for each individual claim. Provides a line item account for each claim represented on the RA Summary Page – provides information that spans all the claims included in the AC section of the SPR 10 5 Part A Medicare Remittance Advice 5/6/2014 Section 1 – contains Medicare contractor and provider information Section 2 – included on every SPR to provide a list of fields that appears for each claim Section 3 – details claim data and consist of nine columns and four lines Medicare Learning Network® (MLN) 11 Medicare Learning Network® (MLN) 12 Section 2 Section 3 6 Part A Medicare Remittance Advice 5/6/2014 Medicare Learning Network® (MLN) 13 Section 2 RED (provider charges submitted on the claim) - BLUE (claim adjustments)_________ = GREEN (net reimbursement) Medicare Learning Network® (MLN) 14 7 Part A Medicare Remittance Advice 5/6/2014 Reading an Institutional ERA 15 Faster communication and payment notification Faster account reconciliation Access to data in a variety of formats Detailed information Paperwork reduction Free Medicare supported-software PC-Print 16 8 Part A Medicare Remittance Advice 5/6/2014 Using PC-Print institutional providers may view and print the following screens: All Claims (AC) Single Claim (SC) Bill Type Summary (BS) Provider Payment Summary (PS) Downloadable at no cost www.cahabagba.com/documents/2012/08/pc-print-userguide.pdf 17 All Claims (AC) Screen Section 1 – contains field names of each position in the AC record Section 2 – contains the claim data Medicare Learning Network® (MLN) 18 9 Part A Medicare Remittance Advice 5/6/2014 Header Information Single Claim (SC) Screen Charges Section CARCs and RARCs Days and Visits Contains data for SNF or HHA claims Payment Data Information Medicare Learning Network® (MLN) 19 Bill Type Summary (BS) Medicare Learning Network® (MLN) 20 10 Part A Medicare Remittance Advice 5/6/2014 Provider Payment Summary PLB Adjustment Code Medicare Learning Network® (MLN) 21 All Claims (AC) Screen RED (charges submitted on the claim) - BLUE (claim adjustments)_________ = GREEN (net reimbursement) Medicare Learning Network® (MLN) 22 11 Part A Medicare Remittance Advice 5/6/2014 All Claims (AC) Screen $16,998.00 (charges submitted on the claim) - $13,713.23(claim adjustments)_________ $3,284.77= (net reimbursement) Medicare Learning Network® (MLN) 23 Cahaba GBA EDI Services department 866-582-3253 Fax: 205-402-5706 Email at [email protected] Contact the Provider Contact Center (PCC) for questions regarding received remits 877-567-7271 24 12 Part A Medicare Remittance Advice 5/6/2014 $5.00 per copy ERA available to download for 45 days Form available at www.cahabagba.com/documents/ 2012/02/part-a-remit_dup.pdf 25 Cahaba University www.cahabagba.com/part-a/education/cahaba-u-18358/computer-basedtraining/ CMS Web Based Training Module “Understand the Remittance Advice for Institutional Providers” www.cms.gov/MLNproducts Understanding the Remittance Advice www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/ra_guide_full_03-22-06.pdf CMS Manual, Publication 100-04, Ch. 22 www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c22.pdf 27 13 Part A Medicare Remittance Advice 5/6/2014 We want to hear from you! Rate your Cahaba GBA experience Quality of information Freshness of content Clarity of organization Location of information Consistency of speed Overall satisfaction 29 Questions For claim specific inquiries, please contact the Provider Contact Center at 877-567-7271 28 14 Part A Medicare Remittance Advice 5/6/2014 http://listmgr.cahabagba.com/subscribe/survey?f=1602 29 15