Interactive Remittance Advice
References:

CPT codes, descriptions, and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Contractor Contact Information:

Name, address and telephone number of the Medicare contractor that processed the claim(s) and produced the Medicare Remittance Advice.

Medicare Remittance Advice Number:

This is the remittance advice number or serial number. It is shown on all pages of each remittance advice.

Provider Information:

Provider's name and address ('billing provider').

General Medicare Remittance Information:

  • NPI - the NPI of the provider receiving the Medicare Remittance Advice ('billing provider').
  • Page Number - Current page number and total number of pages in the Medicare Provider Remittance Advice.
  • Date - Date the remittance was issued. Important: unless the service is 'returned as unprocessable' because of a billing error (designated iwth remark code MA130), this date is considered the 'initial determination date.' For services that are denied or only partially paid any appeals must be filed within 120 days of the initial determination.
  • Check/Electronic Fund Transfer (EFT) Number - This field indicates the check or EFT transaction number through which payment was issued. If a paper check is issued, this field contains the check number. If no payment is issued, this field displays the Remittance Advice number.

Provider Bulletin Board:

This area, boxed in with asterisks, contains contractor-specific information for the provider. The bulletin board section is only provided on the first page of the Medicare Remittance Advice.

Claim Section (Header Row):

The assigned claims section starts with a header row. This header row provides labels for the data displayed for each claim included on the remittance advice.

After the header row, claims are listed individually. Each claim starts with 'Name' in the upper left, and ends with 'NET', and an amount, in the lower right. A single line separates each claim. Beneficiary names are displayed on the Medicare Remittance Advice in alphabetical order by last name.

The first six fields apply to the claim as a whole (Name, HIC, ACNT, ICN, ASG, and MOA sections). Claim information is then broken out at a service-line level.

  • perv prov = performing provider
  • serv date = service date
  • pos = place of service
  • nos = number of services
  • proc = procedure
  • mods = modifiers
  • billed = billed amount
  • allowed = allowed amount
  • deduct = amount applied to deductible
  • coins = amount applied to coinsurance
  • GRP/RC-AMT = Group/Reason Code Amount
  • prov pd = provider paid amount

Name:

This field contains the last name and first name of the patient for whom the claim was processed ('billing provider'). If a claim was submitted using the beneficiary name Jane Smith, but during processing Medicare records in the Common Working File (CWF) indicate the name of record for that patient is listed as Jane Jones, then the Medicare Remittance will display the name 'Jones, Jane' in this field.

Health Insurance Claim (HIC) Number:

This field indicates the Health Insurance Claim (HIC) number of the patient that received the services. For example, a claim was submitted by the provider using the HIC number 000000000A. If the patient's HIC number was changed to 000000000B in the Medicare eligibililty system, then the Medicare Remittance Advice will display HIC number 000000000B in this field.

Account Number (ACNT):

This field contains any internal account number assigned to the claim by the provider, such as a patient account number, that was submitted on the claim.

Internal Control Number (ICN):

The 13-digit ICN is a unique number assigned by Palmetto GBA to the claim at the time it is received. It is used to track and monitor the claim.

Assignment (ASG):

This field indicates whether the provider has accepted assignment for these claims. This field contains either a 'Y' for yes or an 'N' for no.

  • 'Accepting assingment' means that the provider has agreed to accept the Medicare allowed charge amount as payment in full for his/her practitioner services.
  • The following practitioners must accept assignment for all Mediare covered services they furnish:
    • Specialty 32 - Anesthesiologist assistants (AAs)
    • Specialty 42 - Cetrified nursh midwives
    • Specialty 43 - Certified registered nurse anesthetists (CRNAs)
    • Specialty 50 - Nurse Practitioner
    • Specialty 68 - Clinical Psychologists
    • Specialty 71 - Reistered dietitians/nutritionists
    • Specialty 73 - Mass Immunization Roster Billers
    • Specialty 80 - Clinical Social Workers
    • Specialty 89 - Clinical nurse specialists
    • Specialty 97 - Physician assistants

Medicare Outpatient Adjudication Reason Code or Claim Adjustment Reason Code (MOA):

This field contains Remittance Advice Remark Codes (RARCs) or Claim Adjustment Reason Codes (CARC) at the claim level. These codes and their meanings are listed in the glossary section at the end of the Medicare Remittance Advice. RARCs and CARCs are used to convey appeal information and other claim-specific information providing additional explanation for claim-level adjustments. A complete listing of these codes is available at www.wpc-edi.com/codes.

  • MA01 - Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.

Performing Provider (PERF PROV):

This field displays the performing/rendering provider transaction access number (PTAN). If there is more than one performing provider, only the first is included.

The PTAN does not display on this remittance.

Service Date (SERV DATE):

This field displays the date(s) of service.

Place of Service (POS)

This field indicates the two-digit Place of Service (POS) code.

Number of Services (NOS):

This field displays how many services were submitted (number of units).

Procedure Code (PROC):

This field indicates the Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) procedure code submitted for the service.

Modifiers (MODS):

This field displays all modifiers billed with the specified procedure/service.

Billed Amount (BILLED):

This field displays the amount that the provider billed for the procedure/service.

Allowed Amount (ALLOWED):

This field displays the Medicare-allowed amount for the service.

Amount Applied Towards Deductible (DEDUCT):

This field displays the amount of any deductible applied to the service. If an amount is displayed in this field, this is the amount that the patient (or other insurer, if applicable) is responsible for paying the provider.

Some supplemental insurance plans may cover the deductible amount. NOTE: Deductible amounts are subject to change annually.

For 2010, the Part B deductible is $155.00 for the year.

For 2011, the Part B deductible is $162.00 for the year.

Coinsurance Amount (COINS):

This field displays the coinsurance amount. If an amount is displayed in this field, this is the amount that the patient (or other insurer, if applicable) is responsible for paying the provider.

For Part B coinsurance, the patient is responsible for 20 percent of the allowed charges.

NOTE: Coinsurance amounts are subject to change annually.

  • Coinsurance does not apply to certain services, including most clinical laboratory services and flu and pneumonia vaccines.
  • The coinsurance for most outpatient mental health care differs based on the year the service was provided. For more information on the “Outpatient Mental Health Treatment Limitation,” refer to MLN Matters article MM6686 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6686.pdf on the CMS Web site.
  • The following chart shows the changes in coinsurance amounts, by year for outpatient mental health services:
    Service Dates Limitation % * % Medicare Pays ** % Patient Pays**
    12/31/09 or before 62.5% 50% 50%
    1/1/10 - 12/31/11 68.75% 55% 45%
    1/1/12 -12/31/12 75% 60% 40%
    1/1/13 - 12/31/13 81.25% 65% 35%
    1/1/14 and after 100% 80% 20%
    * % of fee schedule amount     **of the Limitation %

Group/Reason Code (GRP/RC):

This field contains any Group Codes and Claim Adjustment Reason Codes (CARCs) associated with this service line. There are four possible Group Codes for Medicare.

  • CO: Contractual Obligation - Used when a contractual agreement between Medicare and the provider, or a regulatory requirement, resulted in an adjustment. When CO is used to describe an adjustment, a provider is not permitted to bill the beneficiary for the amount of that adjustment. Group Code CO is always used to identify excess amounts for which the law prohibits Medicare payment and absolves the beneficiary of any financial responsibility, such as: participation agreement violation amounts, limiting charge violations, late filing penalties, and amounts for services not considered being reasonable and necessary.
  • CR: Correction and Reversal - Used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim.
  • OA: Other Adjustment - used when no other Group Code applies to the adjustment
  • PR: Patient Responsibility - Represents an adjustment amount that is billed to the beneficiary or insured. This Group Code is typically used for deductible and co-insurance adjustments.

Codes listed for a service line of a claim are listed along with their definitions in the glossary section of the Medicare Remittance Advice. A complete listing of CARCs is available on this Web site: http://www.wpc-edi.com/codes.

CO-50

  • CO - Contractual Obligation.
  • 50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.

Group/Reason Code Amount (GRP/RC - AMT):

The AMT field contains the amount of any adjustment that was made based on the preceding Group Code and CARC.

Provider Paid Amount (PROV PD):

The amount the provider is paid for this service.

Remark Codes (REM):

This field contains any Remark Codes associated with this service line. Codes listed for a service line of a claim are listed along with their definitions in the glossary section of the Medicare Remittance Advice. A complete listing of CARCs is available on this Web site: http://www.wpc-edi.com/codes.

  • M25 - The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amount. We will recover the reimbursement from you as an overpayment.
  • N115 - This decision was based on a Local Medical Review Policy (LMRP) or Local Coverage Determination (LCD). An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd or if you do not have Web access, you may contact the contractor to request a copy of the LMRP/LCD.

HCPI:

This field is reserved for HIPAA Version 5010.

Patient Responsibility (PT RESP):

This is the total amount (for the claim, including all service lines) that the patient (or other insurer, if applicable) is responsible for paying the provider.

Claim Total Billed Amount (BILLED):

This field displays the total amount that the provider submitted for the claim.

Total Allowed Amount:

This field displays the total Medicare-allowed amount for all claims included on this remittance advice.

Claim Total Deductible Amount:

This field displays the total amount applied toward the patient's deductible for the entire claim.

For 2010, the Part B deductible is $155.00 for the year.

For 2011, the Part B deductible is $162.00 for the year.

Claim Total Coinsurance Amount:

This field displays the patient's coinsurance amount for the claim.

For Part B coinsurance, the patient is responsible for 20 percent of the allowed charges.

NOTE: Coinsurance amounts are subject to change annually.

  • Coinsurance does not apply to certain services, including most clinical laboratory services and flu and pneumonia vaccines.
  • The coinsurance for most outpatient mental health care differs based on the year the service was provided. For more information on the “Outpatient Mental Health Treatment Limitation,” refer to MLN Matters article MM6686 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6686.pdf on the CMS Web site.
  • The following chart shows the changes in coinsurance amounts, by year for outpatient mental health services:
    Service Dates Limitation % * % Medicare Pays ** % Patient Pays**
    12/31/09 or before 62.5% 50% 50%
    1/1/10 - 12/31/11 68.75% 55% 45%
    1/1/12 -12/31/12 75% 60% 40%
    1/1/13 - 12/31/13 81.25% 65% 35%
    1/1/14 and after 100% 80% 20%
    * % of fee schedule amount     **of the Limitation %

Claim Total Group/Reason Code & Amount (GRP/RC - AMT):

This field contains the total amount of any adjustments that were made for the claim (including all service lines).

Claim Total Provider Paid Amount:

The amount the provider is paid for this claim.

Net:

The net amount the provider is being paid associated with this remittance advice. This total includes interest, if applicable

Total Number of Claims:

Number of claims included on this remittance advice.

Total Billed Amount:

The total billed charges included on this remittance advice.

Total Allowed Amount:

This field displays the total Medicare-allowed amount for all claims included on this remittance advice.

Total Deductible Amount:

This field displays the total amount applied toward the patient's deductible for all claims included on this remittance advice.

For 2010, the Part B deductible is $155.00 for the year.

For 2011, the Part B deductible is $162.00 for the year.

Total Coinsurance Amount:

This field displays the patient's coinsurance amount for all claims included on tis remittance advice.

For Part B coinsurance, the patient is responsible for 20 percent of the allowed charges.

NOTE: Coinsurance amounts are subject to change annually.

  • Coinsurance does not apply to certain services, including most clinical laboratory services and flu and pneumonia vaccines.
  • The coinsurance for most outpatient mental health care differs based on the year the service was provided. For more information on the “Outpatient Mental Health Treatment Limitation,” refer to MLN Matters article MM6686 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6686.pdf on the CMS Web site.
  • The following chart shows the changes in coinsurance amounts, by year for outpatient mental health services:
    Service Dates Limitation % * % Medicare Pays ** % Patient Pays**
    12/31/09 or before 62.5% 50% 50%
    1/1/10 - 12/31/11 68.75% 55% 45%
    1/1/12 -12/31/12 75% 60% 40%
    1/1/13 - 12/31/13 81.25% 65% 35%
    1/1/14 and after 100% 80% 20%
    * % of fee schedule amount     **of the Limitation %

Total Reasonable Charge Amount:

This field indicates the total amount of adjustments made to assigned claims due to the Claim Adjustment Reason Codes (CARCs) listed on each service line. This excludes interest, late filing charges, deductibles, and amounts previously paid for rendered services.

Total Provider Paid Amount:

The amount the provider is paid for all claims included on this remittance advice.

Total Provider Adjustment Amount:

The amount of any adjustments made on all claims included on this remittance advice. The Group Codes and CARCs explain the reasons for any adjustments made.

Total Check Amount:

The amount reflected on the check associated with this remittance advice.

Glossary:

Group, Reason, and Remark codes and their descriptions. Refer to this section for detailed explanations for any informational messages, denials, and adjustments. For detailed assistance with the most common denials, refer to the Palmetto GBA Denial Resolution Tool (accessible from the home page for your state except for Railroad Medicare).