Understanding Your Remittance Advice. HP Provider Relations/2014 IHCP Annual Seminar

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1 Understanding Your Remittance Advice HP Provider Relations/

2 Agenda Session Objectives Remittance Advice (RA) General Information Financial Transactions RA Summary Page Stale-Dated and Reissued Checks Helpful Tools Questions 2

3 Objectives Following this session, providers will be able to: Understand the purposes of the RA Learn how to access and understand the weekly RA Summary Page Understand specific financial transactions, refunds, accounts receivables (A/Rs), and claimand nonclaim-specific transactions Understand the benefits of the electronic funds transfer (EFT) 3

4 Remittance Advice

5 Remittance Advice General information The most significant tool an Indiana Health Coverage Programs (IHCP) provider has to monitor participation in the program is the weekly RA. The RA provides information about claims processing and financial activity. Web interchange Claim Inquiry/Show More Claim Information functions provide similar information for individual claims. The Health Insurance Portability and Accountability Act (HIPAA) 835- Health Care Claim Payment Advice is the electronic version of the paper RA. 5

6 Remittance Advice General information the RA: Lists all claims processed during a particular week Is the main claim and payment tracking device for providers Is available each Monday via Web interchange Is no longer available via Web interchange after four weeks Duplicate paper copies of the RA may be requested for 15 cents per page 6

7 Remittance Advice General information Sorts the claim information according to claim type and status (paid, denied, in process) Identifies claims in process (not finalized): suspended claims and claims in the adjustment cycle Suspended claims appear on the RA for the week in which they first suspend and the last RA each month only The RA outlines claim information at the header level (claim level) and the detail level (service line level) A total for each section of the RA appears at the end of each section Each managed care entity (MCE) establishes and communicates its own financial processes 7

8 Click here to download the RA EVERY week 8

9 RAs are available for the current and four prior weeks. 9 Click on the check # to see the paid claim details.

10 Remittance Advice How do I obtain a copy of an RA? Request a paper RA by calling HP Customer Assistance at A Customer Assistance analyst verifies the number of pages of the RA requested and calculates the payment at $.15 per page. Checks must be made payable to the IHCP and mailed with a written request to: HP Provider Written Correspondence P.O. Box 7263 Indianapolis, IN

11 Financial Transactions

12 Financial Transactions The financial transaction section of the RA provides information about claimspecific and nonclaim-specific transactions: Payouts Refunds Accounts Receivable (A/R) 12

13 Payouts Claims in a paid status, including claims paid at zero dollars, such as crossover claims, claims that include third-party liability (TPL), and claims impacted by spend-down An example of a zero-paid claim is a claim for a member with other insurance when the other insurance paid an amount equal to or greater than the IHCP-allowable amount 13

14 Reading Crossover Payments Medicare paid Medicaid allowed Balance Medicaid due to provider.00 Medicaid paid amount Medicaid allowed amount 14

15 Reading TPL TPL Payment Medicaid Payment TPL Paid = Medicaid allowed = Medicaid Paid =.00 Explanation of benefits (EOB) will read No payment made-tpl/spenddown is more than the Indiana 15 Understanding Health Your Medicaid Coverage Remittance Advice Program allowed 2014 IHCP Annual amount Seminar

16 Inpatient HAF Pricing Pricing (HAF) ARC Amounts REF Comments A - Billed Amount $ 76, Provider billed amount from claim B - Med Allowed Adj B22 $ (66,895.70) C - Base/Allowed $ 10, DRG-LOC Base Adjustment to Medicaid Allowed amount D - HAF Adjustment 169 $ 20, HAF adjustment factor (3x) Outlier $ - Outlier Payment (if applicable) E GME 75 $ Graduate Medical Education F - Capital Cost 94 $ Capital Cost reimbursement H TPL $ - Third Party Liability paid to provider I - Patient Resp 178 $ - Patient Responsibility J - Paid Amount $ 31, Medicaid Amount paid to provider 16

17 Accounts Receivable (A/R) An A/R is money determined by the State or one of its contractors to be payable to the IHCP from an enrolled provider (overpayment). An A/R may also occur when a provider has adjusted a claim or requested a claim adjustment. 17

18 Accounts Receivable (A/R) IndianaAIM automatically establishes an individual A/R for an adjustment in which the net reimbursement of the adjustment is less than the original payment. A/R control numbers identify these system-generated A/Rs on the RA. 18

19 Accounts Receivable (A/R) System-generated A/Rs can be identified on the Remittance Advice (RA) as A/Rs with control numbers that begin with the number 5: 50 Provider-Initiated Noncheck-Related Adjustments 51 Provider-Initiated Check-Related Adjustments 54 Void Transaction 55 Mass Adjustment Nursing Facility Retroactive Rate 56 Mass Adjustment 59 Point of Service (POS) Reversal Adjustment 19

20 Accounts Receivable (A/R) If an A/R has not been recovered after 15 days, HP will mail a letter requesting a full refund or transfer of the amount due. If there is still no response in 10 days, the A/R is transferred to recoup the amount due to another provider number that shares the same tax identification number (TIN). If the A/R is not satisfied in another 15 days, a request for referral to the Attorney General s Office may be sent to the FSSA. 20

21 Nonclaim-Specific Financial Transactions Non-claim-specific financial transactions are transactions unrelated to a particular claim that affect a provider s payment. Non-claim-specific refunds are refunds made by a provider to the IHCP that cannot be directly tied to a specific claim. Non-claim-specific payouts are payments made to a provider that are not specific to a member or date of service. 21

22 RA Summary Page

23 RA Summary Page Data from the entire RA is included on the summary page. The summary page summarizes all claim and financial activity for each weekly cycle and reports year-to-date totals. 23

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25 Stale-Dated and Reissued Checks

26 How to Request Reissue of a Check To request the reissuance of a payment check, providers may call the HP Customer Assistance Unit at Finance will not reissue a check if a provider s pay to address is out of date. Checks are mailed to the current pay to address. 26

27 Stale-Dated Checks If a check is not presented for payment within 180 days after the date of issuance, the check is stale-dated and will not be honored for payment. When a check is voided because it is staledated, or for any other reason, HP voids the check and any associated claims from IndianaAIM. 27

28 How to Avoid Reissued and Stale-Dated Checks Providers are strongly encouraged to consider Electronic Funds Transfer (EFT), which automatically deposits payments into their bank accounts each week. EFT payments have several advantages: Decrease the provider s administrative processing required by paper checks Are safe and allow the deposit of funds into only a designated account Eliminate lost, misplaced, voided, and stale-dated checks It takes less than five minutes to change to EFT via Web interchange! 28

29 Find Help

30 Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Manual Chapter 12 Financial Services Customer Assistance Provider Relations field consultant Locate area consultant map on: indianamedicaid.com (provider home page > Contact Us > Provider Relations Field Consultants) Web interchange > Help > Contact Us Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN Subscribe to Notices 30

31 Q&A