Transcript Slide 1

Remittance Advice and
Financial Updates
Presented by
EDS Provider Field Consultants
October 2009
Agenda
• Session Objectives
• Remittance Advice (RA) – General Information
• The 835 Electronic RA
• Sections of the RA
• Codes (EOB, ARC, and REMARK)
• Edits and Audits
• Review of RA Handout
• Accounts Receivable
• Other Provider Level Adjustments
• Primary Medical Provider (PMP) Administrative
Payments
• Voiding Checks
• Electronic Funds Transfers (EFT)
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Session Objectives
At the end of this session, providers will be able to:
• 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 receivable (A/R), claim specific and
nonclaim-specific transactions
• Understand how the EDS system applies edits and
audits to properly adjudicate claims
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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
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Remittance Advice – General Information
Beginning September 1, 2009:
• Providers must access their RAs online through Web
interChange
• RAs will be available at the beginning of the week in
Adobe portable document format (PDF)
• A rolling four weeks of paperless RAs will be available
online
– Once the rolling four weeks has passed, the RA can be
requested by contacting EDS Customer Assistance at
800-577-1278
•
A charge of 15 cents per page will apply
•
Can request whole RAs only
• Copies of the RAs in Adobe PDF may be saved to
providers’ personal storage devices for future reference
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Remittance Advice – General Information
• RAs are issued weekly in an Adobe PDF format
– Providers enrolled in electronic funds
transfer (EFT) receive a copy of their check
via Web interChange
– Providers not enrolled with EFT will obtain
a paper check that will be mailed weekly
• 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
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Remittance Advice
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Remittance Advice – General Information
• RAs provide information about adjudicated
claims that are paid, denied, adjusted, and
claims in process
• 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
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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
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Remittance Advice – Section Descriptions
• Claims in Process – This section lists claims in the
processing cycle that have not yet been finalized, such as
the following:
–Claims that have attachments
–Claims that require manual pricing
–Voids and Replacements that have not finalized
–Suspended Claims
–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, such as inpatient, outpatient, and crossover
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Remittance Advice – Section Descriptions
• Claim Void/Replacements – This section lists claims
that have been voided or replaced
–Each adjusted claim shows 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 nonclaim-specific
payouts, refunds, and accounts receivable (A/R)
transactions
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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
– These codes provide the most information as to why
the claim denied
• ARC Code Descriptions – This section lists Adjustment
Reason Codes (ARCs) along with respective code
narratives that reflect the adjustments in payment
between billed amounts and allowed or payment amounts
Note: The narratives for EOB and ARC codes are listed at the
end of the RA
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Remittance Advice – Section Descriptions
The Summary page reiterates all claim and financial activity
for each weekly cycle and gives year-to-date totals
• Claims Data
– This subsection contains current and year-to-date totals for
claims paid, claims adjusted, interest, claims denied and in
process
• Earnings Data
– This subsection 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 subsection contains current and year-to-date totals for
payments to lien holders, if applicable
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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
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EOB Examples
Code
Description
Provider Action
Required
0203
Recipient ID number is
missing
Resubmit claim with 12digit 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
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Adjustment Reason Codes
• A complete list of adjustment reason codes (ARCs)
is available on the Washington Publishing Company
Web site: www.wpc-edi.com/codes/
• ARCs are alphanumeric codes from an external
national code set used with the 835 transaction
• ARCs are reported at HEADER and DETAIL levels
immediately following claim information
• All claims on the RA also include Adjustment
Remark Codes
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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 alphanumeric, 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
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EOBs / ARCs / REMARKS Examples
EOB
ARC
Remark
0203 – Recipient I.D.
number is missingPlease 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
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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 set forth by Office of
Medicaid Policy and Planning (OMPP) and
Centers for Medicare & Medicaid Services
(CMS)
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Types of Edits
• Validation Edits (EOB 0100 to 0499) – used to validate the
presence and format of data entered on the claim
Most Common - 0202 – Billing Provider ID in Invalid
Format
• Relational Edits (EOB 0500 to 0899 and 8000 to 8999) –
used to compare or relate multiple fields on the current claim
Most Common - 0558 – Coinsurance/Deductible Amount
Missing
• Provider Edits (EOB 1000 to 1999) – are performed on the
provider identification numbers such as billing, rendering, and
referring NPI
Most Common - 1000 – Billing Provider ID Number Not on
File
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Types of Edits
• Recipient Edits (EOB 2000 to 2999) – are performed on the
member identification number (RID) to ascertain member
eligibility
Most Common - 2017 – Recipient Ineligible in DOS
• Prior Authorization Edits (EOB 3000 to 3999) – are
performed to ascertain that billed services requiring prior
authorization are prior authorized
Most Common - 3001 – DOS Not on PA Master File
• Reference Edits (EOB 4000 to 4999) – check various
reference tables used in claims processing, such as
formulary file, procedure code table, modifier table, and
pricing table
Most Common - 4021 – Procedure Code Vs. Program
Indicator
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More Edits
• SURS Edits (EOB 7000-7999) – were
established to allow Surveillance and Utilization
Review (SUR) examiners to perform
prepayment administrative reviews on
identified providers and recipients
Most Common - 7002 – Claim Denied for
Drug Utilization Review (DUR) Reasons
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Types of Audits
• History-Related Audits (EOB 5000 to 5999) –
compare the current claim with paid claims in
history to determine if a claim is a duplicate of
a previously paid claim
 Most Common - 5001 – Exact Duplicate
• Medical Policy Audits (EOB 6000 to 6999) –
track and restrict certain services based on
eligibility and coverage policy set forth by
OMPP and CMS
 Most Common - 6000 – Manual Pricing
Required
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RA Handout Review
Please refer to your RA handout
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Accounts Receivable (A/R)
• An accounts receivable is established when the
OMPP or one of its contractors determines that a
provider owes money to the IHCP
• An accounts receivable may be established either
automatically or manually
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Accounts Receivable (A/R)
• Automatically established ARs are set up for
adjustments when the net reimbursement is
less than the original payment
• ICNs begin with ‘5’:
50 – Noncheck-related adjustment
51 – Check-related adjustment
54 – Provider voids check with adjustment
55 – Long-term care (LTC) retro-rate
adjustments
56 – Mass adjustments initiated by EDS
59 – Point of Service (POS) reversals
62 – Electronic replacement
63 – Electronic void
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Accounts Receivable (A/R)
• Manually established ARs are set up for:
 Repayment Agreements
 Tax Assessments for Intermediate Care Facilities
for the Mentally Retarded (ICF/MR) and
Community Residential Facility for the
Developmentally Disabled (CRF/DD)
 SUR Audits
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Accounts Receivable (A/R)
• Four methods to recoup an A/R:
–The claim offset process occurs when the A/R is
systematically deducted from the weekly RA
payment until the full amount is recouped
–The provider recognizes that an overpayment exists
and sends a refund check to satisfy the A/R
–The provider makes an agreement to make
installment payments
–An inactive provider number’s A/R is transferred to
another active provider number that shares the same
tax identification number
• If an A/R is not recovered within 15 business days, EDS
mails a transfer letter (if the provider shares a common
TIN with another provider), or a demand letter
requesting repayment
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Other Provider Level Adjustments
• ICF/MR and CRF/DD Tax Assessments
–An assessment in conjunction with the rate-setting
process
• System Payouts (Nonclaim-specific)
–When a provider is due a refund that cannot be tied to
a specific claim
• Partial Provider Payment and Repayment Agreements
–When a provider has specific claims processing issues
that are causing an undue financial hardship
• Nonclaim-Specific Refunds
–When a provider refunds money that cannot be tied to
a specific claim
• Liens Against Provider Payments
–When EDS must process IRS or court-ordered liens
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Primary Medical Provider – Monthly
Administrative Fee
• Providers who participate in Care Select as primary
medical providers (PMPs) receive a monthly
administrative fee per member
– $15 per member per month
– A panel of 150 members = $2250
• The aggregate administrative fee payment appears
on the summary page of the RA under the heading
Managed Care Administrative Payment
• Both the current and year-to-date administrative
fee payments made to the PMP are listed
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Voiding a Check
• A provider that receives an IHCP check and wants to
return the entire amount, can return the check to
EDS for voiding
• The claims associated with that check will be voided
automatically
• When necessary, claims must be resubmitted to
EDS for processing
• A provider can initiate a check void for the following
reasons:
–The wrong provider received the payment
–The IHCP incorrectly paid the claim twice
–The payment was made payable to the wrong
service location
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Stop Payment and Check Reissue
• A stop payment request should be made when:
–The provider does not receive its check within 14
calendar days after the RA has been posted to the
Web
• To request that a check be reissued, call the EDS
Customer Assistance Unit at (317) 655-3240 or
1-800-577-1278
• The provider must confirm the Pay To address
• EDS will confirm that the check has not cleared before
stopping payment and reissuing a check
• Avoid reissues by:
–Keeping addresses current in your Provider Profile
• View your provider profile online via Web
interChange
–Enrolling in Electronic Funds Transfer (EFT)
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Electronic Funds Transfer (EFT)
• Advantages:
–Expedites cash flow
–Prevents lost checks
–Automates deposits to your account
–Cost effective
–Easy to implement
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Electronic Funds Transfer (EFT)
• EFT information on the RA
–EFT check number begins with ‘9’ and can be seen via
Web interChange
•
Payment is directly deposited to your account
–EFTs deposited by Wednesday each week
•
If no deposit occurs, call Customer Assistance
• When EFT rejections occur, provider will receive a paper
check instead
–Common reasons for lack of deposit:
•
Wrong bank routing number
•
Incorrect account number
•
Account has been closed
–To correct, please update on the Web interChange
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Electronic Funds Transfer (EFT)
How to Enroll
• Providers can enroll to receive EFTs via Web
interChange under the Provider Profile menu option
• Providers may also complete a paper EFT form
–www.indianamedicaid.com – Click Provider Services,
Provider Enrollment
•
Complete the EFT form
•
Include a voided check with the EFT form and mail
to provider enrollment
–Allow four weeks for processing
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Electronic Funds Transfer (EFT)
• How EDS coordinates with your bank
–EDS must have the American Banking Association
(ABA) transit routing number
–Your bank account number for deposit and type of
account (for example: checking or savings)
–What action is being authorized
•
Start
•
Change
•
Cancellation
–If all is in order, EFT will begin within three payment
cycles
–Continue to receive paper checks until EFT is
successfully established
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Helpful Tools
Avenues of Resolution
• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Customer Assistance
–1-800-577-1278, or
–(317) 655-3240 in the Indianapolis local area
• Written Correspondence
–P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations field consultant
–View a current territory map and contact
information online at www.indianamedicaid.com
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Questions
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Office of Medicaid Policy and Planning (OMPP)
402 W. Washington St, Room W374
Indianapolis, IN 46204
EDS, an HP Company
950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal
opportunity employer and values the diversity of its people. ©2009 Hewlett-Packard Development Company, LP.
October 2009