Anthem Commercial Remittance Advice Explanation

Transcription

1 Anthem Commercial Remittance Advice Explanation Cover Page Information Provider Name and Address Remittance Date Check Number or Automatic Clearing House (ACH) Deposit trace number o If ACH, ABA and Account Number for deposit will be indicated Provider Tax ID last 4-digits Provider ID Number (NPI or Internal Anthem Provider ID number) Payment Summary o Gross Approved claim amount o Interest paid o Incentive withhold (1) (will appear if applicable) o Net amount due o IRS withhold (will appear if applicable) o Amount previously overpaid o Amount Disbursed o Recoupment balance General remittance message Header Information If a check (or ACH deposit) is enclosed to the provider this info will start on the second page. If there is no check for the provider this information will follow directly after the zero amount-this is not a check statement. Provider Name Provider ID Number Remittance Date Check Number (if applicable) Number of pages Product Name (multiple product types will be included in each remittance) Detail Content Line 1 Insured s Name, Insured s ID # and the Patient s name appear on line one across all columns Line 2 Your Patient Account #, Claim # and Claim Receipt Date (Received) appear as the second line displayed across all columns Line 3 Service Provider Name and ID number appear as line 3 across several columns. Line 4 Column Totals per patients per claim. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Revision Date: March

2 Service Detail Columns Column Header Service Date Service Codes POS Charge Allowed Deductible Coinsurance Co-pay Contractual Difference Provider Resp. Amount Expl/ANSI Code(s) Insured Other Resp. Amount Expl/ANSI Code(s) Net Paid Definition/Value From and thru service dates CPT, HCPCS OR Revenue Codes Billed Place of service code The amount billed for the procedure or service The contracted amount allowed for the procedure or service The amount of the member s deductible that has been applied to the procedure or service. Provider can bill the member for this amount The amount of the member s coinsurance that has been applied to the procedure or service. Providers can bill the member for this amount The amount of the member s co-pay that has been applied to the procedure or service. Providers can bill the member for this amount This field may be blank. When information is present, it is the contracted rate (discount) between you and Anthem BlueCross and BlueShield This field may be blank. When information is present, this is the amount that you are contracted to write off that is outside of your contractual amount. Example may be contractual discount or bundled charges Payment, Reduction or Rejection reason code(s) This field may be blank. When information is present, this is the amount the insured or responsible party may be liable for excluding deductible, coinsurance and copay Payment, Reduction or Rejection reason code(s) Total amount paid for the procedure or service. Product Summary appears after the last claim for the product Total Approved Amount Total Interest Total Withhold (1) (will appear if applicable) Total Net Amount Due/Product Name Gross Summary appears at the end of the remittance advice Gross Approved Claim Amount Total Interest Total Withhold (1) (will appear if applicable) Net Amount Due EXPL (Explanation)/ANSI Code Descriptions will appear at the end of your remittance advice. (1) The Incentive Withhold will be taken at the line level and not the claim level. The money will appear in the Provider Responsibility column and the message will be RWD which the explanation code will be Risk Withhold Disallowed. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Revision Date: March

3 Recoupment Notification-If Applicable will appear at the end of your remittance after the text above and will include Column Header Remit Date Patient Name Patient Acct Subscriber ID Claim Number Date of Service Original Negative Claim Number Claim Amount Credits Recovered ADJ CD Charge Amt Code(s) Recovery Letter ID Definition/Value Date of original remittance advice Name of patient Provider s patient account number (if submitted on claim) Subscribers Identification Number Anthem assigned claim number Date services were rendered Anthem assigned claim number recouped Total amount overpaid and eligible for recoupment Recoupment off-set amount (could be full or partial) until balance is fully satisfied This field may be blank. When information is present, this will reflect the reason for an additional record. Common examples include balance transfers from provider pay to groups no longer used and refunds applied after claims were recouped. Amount originally billed Number that appeared on the refund request letter sent prior to recoupment Summary at the end of this section: Total Negative Balance (original amount due) Total Prior Recoupment (amounts satisfied from prior remittance advice) Total Current Recoupment (amounts satisfied on this remittance advice) Total Outstanding Negative Balance (carried forward to the next remittance advice) Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Revision Date: March

4 ANTHEM BCBS OF WISCONSIN DBA ANTHEM BLUE CROSS AND BLUE SHIELD Example Remittance Advice 1351 WILLIAM HOWARD TAFT ROAD CINCINNATI, OH An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Registerd marks Blue Cross and Blue Shield Association. PROVIDER ID NO TAX ID NO DATE XXXXX8306 4/16/2012 #BWNCQXF *****727 PAY EXACTLY DOLLARS AND 00 CENTS # /DF 3# ABC HEALTHCARE DEPOSITED TO: PO BOX ABA # ELKHART, WI ACC# ON 04/16/12 ACH DEPOSIT MADE - THIS IS NOT A CHECK ANTHEM BCBS OF WISCONSIN DATE 4/16/2012 P.O. BOX LOUISVILLE, KY PROVIDER NAME ABC HEALTHCARE ADDRESS PO BOX ELKHART, WI PROVIDER ID NO TAX ID NO XXXXX8306 CHECK NUMBER: PAYMENT SUMMARY GROSS APPROVED CLAIM 1, IRS WITHHELD 1.75 PREVIOUSLY OVERPAID DISBURSED NET DUE 1, RECOUPMENT BALANCE TO AVOID ANY UNNECESSARY DELAYS IN CLAIMS PROCESSING, PLEASE INCLUDE CURRENT COORDINATION OF BENEFITS (COB) INFORMANTION WHEN SUBMITTING CLAIMS TO ANTHEM. If this were a paper check payment the physical check would follow a perforation and this payment summary. 4

5 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Registerd marks Blue Cross and Blue Shield Association. Example Remittance Advice ABC HEALTHCARE PROVIDER ID NO /16/2012 CHECK NUMBER: BLUE ACCESS INSURED'S NAME: MATTER, ELLEN INSURED'S ID: SSS0914M4916 PATIENT NAME: MATTER, MELISSA FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: RR0898 RECEIVED DATE: 03/15/2012 (866) SERVICE PROVIDER NAME: GOSH, GREGORY SERVICE PROVIDER ID: /10/ /10/ /10/ /10/ /10/ /10/ PSC /10/ /10/ /10/ /10/ /10/ /10/ PSC /10/ /10/ TOTAL INSURED'S NAME: MATTER, ELLEN INSURED'S ID: SSS0914M4916 PATIENT NAME: MATTER, MELISSA FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: RR0898 RECEIVED DATE: 03/15/2012 (866) SERVICE PROVIDER NAME: GOSH, GREGORY SERVICE PROVIDER ID: /10/ /10/ /10/ /10/ /10/ /10/ PSC /10/ /10/ /10/ /10/ /10/ /10/ PSC /10/ /10/ TOTAL INSURED'S NAME: MICHAELS, BETSY INSURED'S ID: HHH PATIENT NAME: MICHAELS, MAURIO FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: XX0009 RECEIVED DATE: 04/11/2012 (866) SERVICE PROVIDER NAME: TIME, ROBERT SERVICE PROVIDER ID: /10/ /10/ , , , , PSC 45 1, , , , , , TOTAL 1, TOTAL APPROVED 1, TOTAL INTEREST 1.75 TOTAL NET DUE: BLUE ACCESS 1,

6 Example Remittance Advice ABC HEALTHCARE PROVIDER ID NO /16/2012 CHECK NUMBER: BLUE TRADITIONAL INSURED'S NAME: MARKS, MARK INSURED'S ID: HHH PATIENT NAME: MARKS, MARY FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: MM0955 RECEIVED DATE: 03/30/2012 (866) SERVICE PROVIDER NAME: ZOOLOO, ZEB SERVICE PROVIDER ID: /03/ /03/ TOTAL INSURED'S NAME: KASENO, DUANE G INSURED'S ID: GGG PATIENT NAME: CASIO, MEGAN FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: WW1137 RECEIVED DATE: 04/01/2012 (866) SERVICE PROVIDER NAME: WILDERNESS, WANDA SERVICE PROVIDER ID: /20/ /20/ /20/ /20/2012 PAID BY OTHER SNE SNE INSURANCE COMPANY TOTAL INSURED'S NAME: DECKER, RICHARD INSURED'S ID: NNN PATIENT NAME: DECKER, RICHARD FOR INQUIRIES CALL: PATIENT ACCOUNT #: CLAIM NUMBER: PP1797 RECEIVED DATE: 04/05/2012 (866) SERVICE PROVIDER NAME: DOCTOR, RITA SERVICE PROVIDER ID: /20/ /20/2012 PAID BY OTHER PSC INSURANCE COMPANY TOTAL TOTAL APPROVED TOTAL INTEREST TOTAL NET DUE: BLUE TRADITIONAL GROSS APPROVED CLAIM TOTAL INTEREST 1, NET DUE , EXPL CODES EXPLANATION PSC THE CHARGE EXCEEDS THE ALLOWED FOR THIS PROCEDURE SNE MEMBER NOT ELIGIBLE FOR BENEFITS 26 CHARGES INCURRED PRIOR TO COVERAGE 45 CHARGES EXCEED YOUR CONTRACTED/ LEGISLATED FEE ARRANGEMENT 6