Remittance Advice and Financial Updates

Transcription

1 Insert photo here Remittance Advice and Financial Updates Presented by EDS Provider Field Consultants August 2007

2 Agenda Session Objectives Remittance Advice (RA) General Information The 835 Electronic RA Sections of the RA Codes (EOB, ARC & REMARK) Edits & Audits Review of RA Handout Accounts Receivable Other Provider Level Adjustments Primary Medical Provider (PMP) Administrative Payments Voiding Checks Electronic Funds Transfers (EFT)

3 Session Objectives 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 receivables (AR), claim specific and nonspecific transactions Understand EOB, ARC and REMARK codes Understand how the EDS system applies edits and audits to properly adjudicate claims

4 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

5 Remittance Advice General Information Providers receive a weekly RA along with their check. Providers enrolled in electronic funds transfer (EFT) receive a copy of their check 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 and the Web interchange HELP function

6 Remittance Advice General Information RAs provide information about adjudicated claims that are paid, denied and adjusted Paper RAs also include information on claims in process, and claims that generate claim correction forms (CCF) CCFs are mailed with the paper RA, along with the weekly Banner Pages Paper RAs, CCFs and Banner Pages are also sent to providers receiving electronic (835) RAs Banner Pages are intended to keep providers abreast of the most recent developments in the IHCP program 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

7 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 Claims in Process- This section lists claims in the processing cycle that have not yet been finalized, such as the following: Claims that have generated CCFs Claims that have attachments Claims that are past filing limit Claims that require manual pricing Voids and Replacements that have not finalized Suspended Claims

8 Remittance Advice Section Descriptions Claims in Process (continued)- 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 (for example: inpatient, outpatient, crossover, home health, and so forth).

9 Remittance Advice Section Descriptions Claim Void/Replacements- This section lists claims that have been voided or replaced. Each adjusted claim will show 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 non-claim specific payouts, refunds, and accounts receivable (AR) transactions

10 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 ARC Code Descriptions- This section lists Adjustment Reason Codes (ARC) along with respective code narratives that reflect the adjustments in payment between billed amounts and allowed or payment amounts The narratives for EOB and ARC codes are listed at the end of the RA

11 Remittance Advice-Section Descriptions Summary - This page summarizes all claim and financial activity for each weekly cycle, and gives year-to-date totals Summary Page Sub-sections Claims Data This sub-section contains current and year-to-date totals for claims paid, claims adjusted, interest, claims denied and in process Earnings Data This sub-section 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 sub-section contains current and year-to-date totals for payments to lien holders, if applicable

12 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 Provider Services; EOB Descriptions EOB codes are considered local codes and are not transmitted in the electronic 835 transaction

13 EOB Examples Code Description Provider Action Required 0203 Recipient ID number is missing 4033 The modifier used is not compatible with the procedure code billed Resubmit claim with 12- digit member identification number (RID) Refer to Current Procedural Terminology (CPT) code manual and resubmit claim with correct modifier

14 Adjustment Reason Codes (ARCs) A complete list of ARCs is available on the Washington Publishing Company Web site: ARCs are alpha-numeric codes from an external national code set used with the 835 transaction ARCs are reported at HEADER and DETAIL levels immediately following claim information Most claims on the RA also include Adjustment Remark Codes

15 Remark Codes (REMARKS) Remark Codes are provided as clarification in conjunction with the Adjustment Reason Codes Remark Codes are also available at Remark Codes are alpha-numeric, 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

16 EOBs / ARCs / REMARKS Examples EOB ARC Remark 0203 Recipient I.D. number is missing- Please 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

17 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 and Medicaid Services (CMS)

18 Types of Edits Validation Edits (EOB 0100 to 0499) - used to validate the presence and format of data entered on the claim Most Common BILLING PROVIDER I.D. 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 COINSURANCE/DEDUCTIBLE AMOUNT MISSING Provider Edits (EOB 1000 to 1999) - are performed on the provider identification numbers such as billing, rendering and referring LPI and NPI Most Common BILLING PROVIDER I.D. NUMBER NOT ON FILE

19 Types of Edits Recipient Edits (EOB 2000 to 2999) - are performed on the RID number to ascertain member eligibility Most Common RECIPIENT INELIGIBLE ON DOS Prior Authorization Edits (EOB 3000 to 3999) - are performed to ascertain that billed services which require prior authorization are prior authorized Most Common 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 PROCEDURE CODE vs. PROGRAM INDICATOR

20 More Edits SURS Edits (EOB ) - were established to allow Surveillance and Utilization Review (SUR) examiners to perform prepayment administrative reviews on identified providers and recipients Most Common Claim Denied for DUR Reasons

21 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 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 Manual Pricing Required

22 RA Handout Review Please refer to your RA handout

23 Accounts Receivable (AR) An accounts receivable is established when 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

24 Accounts Receivable (AR) Automatically established ARs are set up for adjustments when the net reimbursement is less than the original payment. ICNs begin with 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

25 Accounts Receivable (AR) 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

26 Accounts Receivable (AR) Four methods to recoup an AR: The claim offset process occurs when the AR 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 AR The provider makes an agreement to make installment payments An inactive provider number s AR is transferred to another active provider number which shares the same tax identification number If an AR 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

27 Other Provider Level Adjustments ICF/MR and CRF/DD Tax Assessments An assessment in conjunction with the rate-setting process System Payouts (Non-claim 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 Non-Claim 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

28 Primary Medical Provider (PMP)- Monthly Administrative Fee Providers who participate in Medicaid Select as primary medical providers (PMPs) receive a monthly administrative fee per member 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

29 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 previously paid the claims listed on the RA The payment was made payable to the wrong service location

30 Stop Payment and Check Reissue A stop payment request should be made when: The provider does not receive its RA within 14 calendar days after the RA has been mailed The provider receives an RA but the check is not enclosed To request that a check be reissued, call the EDS Customer Assistance Unit at or 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 Using Electronic Funds Transfer (EFT)

31 Electronic Funds Transfer (EFT) Advantages: Expedites cash flow Prevents lost checks Automates deposits to your account Cost effective Easy to implement

32 Electronic Funds Transfer (EFT) EFT information on the RA Paper RA has a check number beginning with 9 Payment is directly deposited to your account EFTs deposited by Thursday 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: Contact Provider Enrollment Unit

33 Electronic Funds Transfer (EFT) How to Enroll Complete an EFT form Click, Provider Services; Provider Enrollment»Include a voided check with the EFT form EDS Customer Service»Indianapolis ( )»All others ( ) Completely fill out the form and sign Submit the form to: EDS Provider Enrollment P. O. Box 7263 Indianapolis, IN Allow four weeks for processing

34 Electronic Funds Transfer (EFT) How we coordinate with your bank We 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

35 Helpful Tools Avenues of Resolution IHCP Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant View a current territory map and contact information online at

36 QUESTIONS