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Remittance slip example for Financial Services

hello welcome to our presentation understanding the access remittance advice this presentation will cover the electronic remittance advice or er a which is an electronic version of a payment advice the ER a provides explanations regarding how the claims reimbursed by the payer a paper copy is called the remittance advice or RA the ER a will detail the paid amount identify excluded or non covered charges and to be able to quickly identify the denial reasons many payers may use standard ER AIDS with similar denials however many payers will also create their own format for the ER a or remittance advice understanding the information presented on Durham it will help to improve your daily operations identify claims that may require additional action resolve disputed claims and postings of payment so let's get started these materials are designed for fee-for-service programs including American Indian Health Program tribal regional behavioral health Authority and tribal Arizona long-term care services the basics of a remittance advice is to include the a35 transaction is to communicate the claim submitters the reasons why build services are paid or denied both the current paper remit used by access and the electronic 8:35 transaction have many adjudication code values and messages that serve this purpose the access remittance advice will show the payers claim reference numbers or CRN EFT or check number service codes description of services denial reason codes and remarque explanations at the end of each financial cycle the division of business finance will issue a remittance advice the advice or notice of payment will be sent to each provider that had a claim adjudicate during the current weeks financial cycle the remittance advice is separated into individual reports based on the status of the claim each report provides details for clay that are approved denied hold void unadjudicated including secondary payer claims for example Medicare or other insurance electronic data transaction information these are simply reports that can provide you with data based upon your request type electronically we have the 837 I which is for institutional claims the 837 P for professional services and the 837 D for dental claims the report will be able to submit to you information in regards to the transactions that you submitted to access or to the payer the 8:35 electronic remittance device provides detailed payment information for professional and institutional claims as well as dental claims the a34 transaction is for enrollment and disenrollment this will transmit enrollment information from the sponsor of the insurance coverage to a healthcare payer on a daily and monthly basis the a20 ETI capitation payment transaction is a weekly file that provides each access health plan with an electronic remittance advice for its capitation payments the 276 and 277 reports offer claim status requests and responses then this is - the access fee for service for claims that were submitted directly to access administration and will exclude pharmacy benefit manager claim status the 270 and 271 for eligibility request and response is a verification of eligibility coverage and benefit inquiry the 278 is for referral authorization request and response and is used to check the status of a prior authorization request the access Information Services Division EDI customer support is the first point of contact for questions related to electronic transactions or to request transaction setup which is the preferred method of contact is by email if you are providing pho data in your email please make sure your email secur we've also provided the email address which is EDI customer support at AG access gov so requesting your 835 set up access considers the provider our trading partner and a request for electronic remittance device the ER a or 835 transaction setup must come from an authorized individual from within the providers organization it cannot be initiated by the providers Clearinghouse software vendor or billing service the authorized individual must be someone from within the providers own organization that has the authority to accept the electronic trading partner agreement executed from the community manager web portal only the provider can accept the a as it is again a contractual agreement between the provider and access the providers community manager account activation cannot be done by the providers Clearing House software vendor or billing service now setting up your er a account you will need to include your customer name provide your name customer email address access six-digit provider ID or NPI so who will be able to retrieve the e the e ra is 835 B practice for a clearinghouse on behalf of a healthcare provider if the Clearinghouse is to be used include the name of the Clearinghouse in your request so what are some of the benefits of receiving an electronic remittance advice fast and accurate way to post payment details adjustments and denials more detailed payment information for each claim and service line you will be able to view and print information for a single claims and the summary page you will have the ability to share files and reports and also to export that data and of course a reduction in lag time so what information will you find on your 8:35 remit the remittance advice will detail how the claim with process by the payer and will include payer paid amounts deny claims claims that are in avoid status claim adjustments and claims and process the RA will help you to identify any additional actions that may be required to result claim the purpose is to provide detailed payment information relative to the claim and if a put to describe why the total original charges have not been paid in full now let's go over the remittance device the information that you can find on your remittance advice will include the total number of claims and the file your payment amount check EFT number your payee and provider information control numbers with payments or penalty adjustments total provider payment and provider identification numbers we've also listed some of the additional fields that you can view on the remittance advice we will have your patient name claim reference number claim status patient control number score date dates of service billed amount billed units allowed units reason codes also the allowed amount previously paid amounts net paid amount service codes that are fight by the cpt or hit picks modifiers number of claims total billed amount and of course total reMed amount well good about the claim reference numbers a claimed reference number or CRN is assigned to all claims when they are initially submitted to access the first five digits indicate the Julian date of receipt as followed for example this claim reference number is two zero zero two eight six seven eight nine zero zero zero digits one through to reflect the year the claim which received by access 2020 digits three through five indicates the date the claim was received by access so we have zero to eight which is January to twenty eight digit six through ten will indicate how the claim was submitted by paper EDI or even a Medicare cross silver claim in the sixth field of a CRN number if the number is a six that will identify it was an EDI submission if the number is eight that would identify that it was a Medicare crossover claim now on the address page of the remittance advice this will display the billing providers name ID and pay to Mellon address as well as the invoice date and payment date the financial summary page will report payment and invoice data if all claims are in process or denied the page will indicate no active invoices on the financial summary page it would also include the pay for category for acute or long-term care services or even kids care each check number invoice date type and growth payment amount now let's talk a bit about the invoice numbers the invoice number check number and payment date appears on each page of Regents notice invoice numbers are linked to the payment reference number or check number EFT the sixth through eleventh digit of the invoice number and this example six seven eight nine zero one represents the access six digit provider number the last two digits of the invoice number zero one represents the pay to location for the provider the invoice numbers will leak your payments to the services that generated the payment invoice numbers that begin for example with the letter A purpose it acute care services and this would be for petitioners invoice numbers that begin with the letter L will represent all text services and be behavioral health services now let's go over the remittance advice reports the reports are broken down into categories approved denials void adjustments secondary payer claims and Medicare cross overs informational codes for claim adjustment group codes this will consist of two alpha characters that assign the responsibility of a claim adjustment on the explanation of benefits for example seom for contractual obligations Oh a for other adjustment estimate reason code CA our C provides a reason for a payment adjustment that describes why a claim or service line with paid differently than it was billed remittance advice from our codes are AR C are used to provide additional explanation for an adjustment already described by a claim adjustment reason code or to convey information about remittance processing now let's go over reviewing the remittance advice paid claims to review this section to determine which claims have been paid and if those claims were paid correctly any errors such as claims that have not paid the correct number of units should be submitted within timely filing guidelines noting the original claim reference number or CRN adjusted claims this section will report any claim submitted by the provider as adjustments due to payment or billing error if problem skilled with a claim it may be submitted again of course within the timely filing guidelines this section also will report any claims that were adjusted by access as a result of an audit or review denied claims review each denial reason and determine the action necessary to correct the claim voided claims this section will report any claim submitted by the provider as avoided transaction there are many reasons the claim may be voided these may be claims that have been paid by other insurance and need to be voided so that access can recoup its payment this section also will report any claims that were voided by access as a result of an audit or medical review we could this is an example of a remittance advice for paid claim names the information on each report would be very similar you will be able to view the access medicaid ID number the recipient name your patient control number claim reference number or CRN B status date the procedure codes billed including modifiers date of service billed amount billed units allowed amount and the allowed amount payment at the bottom of each report you will see the total number of claims that have been approved this example and a paid status total billed amount of those claims in addition to the total remit amount denied claims again the information will be similar the billing provider NPI number name of the provider again to include the invoice number check number and payment date the recipient ID will be present in addition to the recipients name your patient encounter claim reference number cpt or hickspicks codes submitted for processing dates of service billed amount and units for claims that are denied we will always present with the denial reason code in this example we have ill all zeros which will indicate eight we will provide you with the health plan ID number in addition to the name of the health plan in this example Stewart health choice of Arizona total number of claims that were submitted that are in a denied status and be total billed amount now some of the common claim denials that we receive are remember not eligible coverage terminated non-covered charges provider not enroll and correct member ID untimely filing coding errors not medically necessary missing claim information additional medical documentation is required prior authorization required duplicate claim on file previously paid claim service not covered for contract types primary payer explanation of benefits is required and services do not match the primary payers explanation of benefits now we've moved into the void report again these same information would be present you're billing a service provider ID tax ID number you see in this example the forms also indicated CMS 1500 claim form over to the right you will see the invoice number check number and payment date again the recipient Medicaid ID number will be present first and last name your patient account number claim reference number score date service that was billed in this example we have zero zero four hundred and the applicable modifier a a B dates of service billed amount and units allowed units and over to the right next to previously paid because this is a void or a recoupment you will see the dollar amount with the negative sign next to it indicating the fabless the amount recouped you will also be presented with a reason code in this example we have MV 0 3 4 and the comments deny adjustment of previous payment as with the other reports you will always see a summary of the total number of claims for that particular reports five total billed amount until will recoup them out with the Medicare crossover claims this is another separate report when this report again same information member ID account number claim reference number procedure codes build build amount units allowed amount and your payment amounts will present in addition you will see the abbreviation MCC for Medicare crossover claim now the provider payment summary page this is will be a combination of all of the services that were submitted on the remittance advice at the top you will see your provider name NPI number check date check EAP number total number of claims in the remittance file total billed amount any adjustments the total loud amount after the adjustment total paid to provider total interest amount if that was applicable and total check or EFT amount now with the remittance advice processing notes page for every denial reason that's presented on your remittance advice that information will present on the remittance advice processing notes page you will see the denial reason code and be presented with a description of that denial reason for example l0 fifty point one indicates recipient enrolled in plan for entire service date span MD zero three four would identify emergency criteria not met and l0 99.1 recipient not eligible or enrolled for entire data service and valid eligibility now let's move on to status in that same exact information using the access online claim status review portal so you will have the claim header the claim number is a 12 care of the number used to Annie CLIA denta fie a claim in the access claims processing system it consists of 1 a 5 character Julian date that is the date the claim was receipt to a one character indicator of the medium by which the claim was received 3 a 1 character type indicator for the source of claims received on tape and for a 5 character sequence number the status date will be the effective date of the claims adjudication be patient account number is a unique number submitted by the provider to identify the recipients claim next we have the service provider ID which may be the six digit provider number or the national provider index number and of course the form type how was the claim submitted to access CMS 1500 ubo for pharmacy claim or dental claim on the price accounting summary you will be able to view the line number the claim status they begin and end service dates the service code which are the cpt and Hickock's codes submitted the billed amount for each line of service and the payment amount for accounting details the sequence number identifies a specific payment or discount that is applied to the claims line item sequence number zero one will indicate the original payment or discount that occurred any additional lines indicate adjustments them may have been applied so you will be able to view the payment status the type and the amount this is a view of one of the access online claim submissions here you will be able to do view accounting details edit history status history and denial reasons your service provider information will always be presented as will the recipient ID this is considered the head information just below that you will be able to view the claim reference number the claim status status date and be recipient ID and your service provider ID number under the price accounting summary you will be able to view each line of service submitted on that individual claim and you will also be able to view the claim status for each individual line of service in this example lines 1 & 2 approved for payment line 3 however denied over to the right under service code you will be able to view each CPT or hick pit code submitted the billed amount for each line of service and the payment amount and again the line number 3 that is in a denied status the payment amount is listed as 0 for line number 3 which is in a denied status you will be able to see each individual line again with the dates of service the service code billed and the billed amount for the line approved for payment if you're just looking at the information for line number two you see that that line is also in an approved status you see the different dates of services September 4 to 2019 your service code billed amount but a little different you will see the allowed amount and the payment amounts because this particular line did approve for payment now let's go over the Edit history on this tap you will be able to view the score number which is the sequential number used to identify a specific edit result that occurred against the claim header or one of his detail lines the line number is a sequential number used to identify a specific service for example doctor's visit or x-rays that are related to the claim the date indicates a day that edit was performed and the Edit failures list the reason codes why a claim failed in edit all claims are extensively edited by the access claims processing system a scorecard is created each time a claim is edit in the access processing system the scorecard summarizes which edits were passed or successful and those that failed which caused an action to be performed and will also indicate the claim actions and status for example edit code h00 1.1 would identify service provider ID field is missing providers may view the status of each claim using the access online provider portal regardless of if you submitted that claim electronically using your Clearinghouse using the access web portal or paper submission on the history tab the Edit history tab you will be able to review the access claim reference number which again is a 12-digit number unique to each individual claim the scored number will indicate each time a process was initiated on that claim the clean claim date shows the last date action was taken on your claim and last adjudication status which shows the status of the claim either paid status mixed status void or denied status now for the status history the sequence number is used to identify a specific adjudication status at a given point in time a clean claim date indicates the date all requested information was provided to access the adjudication status indicates the result again approved denied not adjudicated and that would be the status of the editing process the status date indicates the date the claim header or claim line was adjudicated mixed status are claimed with multiple lines of service that result in either a paid or denied line this is what we consider mixed status and that information would present on the same claim reference number in this example we have a status history and the claim is in a mixed pay status we're looking at score number one and you Pheebs have outlined the claim claim date in this example line number one presents with the denial code l1 12.1 and the description reads modifier number one not valid for procedure so there is is the hint to look at your claim submission the line number one and view the modifier that was indicated on the claim and compare that with this CPT or hit pick code that was also included as you see here in the final reason it states invalid combination of codes which would indicate the cpt code and the modifier at the time of processing did not match now let's move on to the duplicate report request for paper remittance devices or notices these are not available for viewing on the access web portal if a provider requires a copy of that paper remittance advice you will have to contact the finance department to request a paper copy the finance department will impose a fee of $4 per page to reproduce the remittance device for electronic remittance advices or notices the 8:35 these are sent out to the provider / an electronic file at the end of each financial cycle the 8:35 remains on the 8:35 server for 90 days from the payment date to allow you time to download the remit to your desktop and to be able to forward that information to other team members at the time of the 90-day period the 8:35 EDI file is removed from the server the finance department will impose a fee of $25 to reload the file again for access so that will conclude our presentation today if you have any questions please forward your questions to provide our training and the email address is provider training FSS @ AZ access gov thank you