Are You Puzzled By Your Remittance Advice Statement?

PROVIDER QUICK TIPSAre You Puzzled by Your Remittance Advice Statement?The Remittance Advice (RA) Statement explains the actions taken and the status of claims andclaims adjustments processed by DHS during a processing cycle. The Cover Page of the RA isused as a mailing label and contains the “Address” where the RA is being sent. This is followedby an optional Banner Page, the “Detail” page(s) that lists all claims processed during the PAPROMISe daily cycle, and a “Summary” page of activity from the detail page(s.) Finally, thelast page(s) is the “Explanation of Edits Set This Cycle” page(s.)Sample – Cover PageA sample of an RA Banner Page is displayed below. The definitions of the items on the RABanner page are on the second page of this Quick Tip. A PA PROMISe Banner Page will beincluded as part of the first page (or as an insert in the RA Statement) when DHS has a need todisseminate information quickly to the provider community. Please read these Banner Pagescarefully as the information contained may affect your payments.BDCMMA 548 03/11

PROVIDER QUICK TIPSSample – Banner Page1. Provider Identification2. Service Location3. Provider Type4. AlertDefinitions of Items on BannerProvider’s 9-digit PA PROMISe provider number.Provider’s 4-digit service location.Provider type listed on the “Provider Notice InformationForm.”From time to time, DHS may need to disseminateinformation quickly to providers. Unless specificallydesignated for a particular provider type, the informationapplies to all providers. Remittance Advice Alerts(PROMISe Banner Pages) are now on the PROMISe site at:http://promise.dpw.state.pa.us. in the ProviderInformation section. New alerts will be added as they arefinalized.The detail page(s) of the RA statement contain information about the claims and claimadjustments processed during the daily cycles in the reporting period. The claim information isarranged alphabetically by recipient last name. If there is more than one provider servicelocation code, claims will be returned on separate RA Statements for each service location. Aspart of this Quick Tip we have included a sample RA Detail Page. All items have beennumbered and correspond with the matching definitions on the third, fourth, fifth and sixth pagesof this Quick Tip.BDCMMA 548 03/11

PROVIDER QUICK TIPSSample – Detail PageRID:1212121212121Patient Account Number:9Definition of Items on Detail Page1. Provider Identification Number Provider’s 9-digit PA PROMISe provider number.2. Service LocationProvider’s 4-digit service location.3. Provider TypeProvider type listed on the "Provider Notice InformationForm".4. Name and Mailing Address of Address on DHS’s provider files designated to receiveProviderpayment for services.5.Recipient IdentificationRecipient’s 10-digit ID number.Number (RID)6. Recipient NameRecipient name as identified by the Recipient ID Number.Recipients are listed alphabetically within each servicelocation. If the recipient ID on the claim form does notmatch with a number in the system’s files, a blank spaceappears instead of name.7. Patient Account NumberAlpha and/or numeric identifier supplied by you. Thisinformation is especially helpful to you in identifying apatient if the Recipient’s Name appears as a blank space.BDCMMA 548 03/11

PROVIDER QUICK TIPS8. Internal Control Number (ICN)The 13-digit number assigned by DHS to each claim. Thefirst two digits represent the Region Code, the thirdthrough the seventh digits represent the Year and JulianDate (the day of the year the claim was received forprocessing), the eighth through the tenth digits representthe Batch Number, and the eleventh through thethirteenth digits represent the Claim Sequence within thebatch.9. Line NumberNumber of the claim line on the claim form.10. QuantityNumber of services provided as indicated on the claimline.11. Begin Date of ServiceBeginning date that the service was performed, asindicated on the claim form.12. End Date of ServiceEnding date that the service was performed, as indicatedon the claim form.13. Procedure Codes, Modifier, Codes used to identify the types of services that wereDrug ID, and Drug Coderendered. Please consult your provider specific feeschedule for compensable procedure code/modifiercombinations.14. Amount BilledYour usual and customary charge for the service providedas submitted on the claim.15. Amount PaidAmount approved by MA for payment. Please note thatMA pays the lesser of the following: the provider’s usualcharge or the established MA fee for the service/item.16. StatusDisposition of the claim line as of the processing date forthis RA. The status column of the RA indicates whetherthe claim has been paid, denied, or suspended: (P) Paid - A claim, or claim line, that is approvedfor payment. The amount paid by theCommonwealth is listed. If the amount paid is notcorrect, follow the instructions in the Billing Guideto submit a Claim Adjustment. (D) Denied – A claim, or claim line, that is rejected(denied.) Explanation code for the denial is listedin the explanation code column. Look up thecode’s meaning on the Explanation of Edits SetThis Cycle page(s) at the end of the RA.o Check the file copy of the claim submitted tolocate the error.o If the service is compensable, submit a new(16. Cont’d)corrected claim form for the denied claim.Include the Internal Control Number (ICN) (orthe Claim Reference Number (CRN) if theclaim was submitted prior to 3/1/2004) of therejected claim. Please refer to the appropriatebilling guide for location on the claim form toBDCMMA 548 03/11

PROVIDER QUICK TIPSenter the ICN or CRN or enter the applicablearea when electronically billing. (S) Suspended - A claim, or claim line, that issuspended and is being held for manual review byDHS. The explanation code for the suspendedclaim is listed in the Explanation Code column.Look up the code’s meaning on the “Explanationof Edits Set This Cycle” page(s) found at the endof the RA.If your claim has multiple lines, the following should betaken in to consideration when reviewing your RA. If you see that some of the lines have an “S” forsuspense, that means the whole claim is in aSuspend status. Please wait until the claim hasbeen fully adjudicated (paid or denied) beforedeciding to take further action. If you see that line 0 (claim header line) is “D”denied, that means the entire claim is denied. Ifyou believe the claim should not have denied, youmay resubmit the claim. [Note: Do not submit adenied claim as an adjustment. A denied claimcannot be adjusted since no payment wasmade.] If you see that line 0 (claim header line) is “P”(Paid) and some lines have a “D” (denied,) theclaim is considered paid, but the specific line(s)with the status “D” are denied. If you believe theclaim or claim line should not have denied, youmay resubmit that denied claim line. [Note: If youresubmit the whole claim, the lines thatpreviously paid on the first claim will bedenied as a duplicate.]BDCMMA 548 03/11

PROVIDER QUICK TIPS17.ExplanationCommentsCodes18. Patient Status19. DRG20. Revenue Code21. GA Deductible22. Copay Deducted23. Date of Claim Form24. Claim Total Billed25. RA Number XX/00000BDCMor Messages to the provider. The code numbers helpidentify what was incorrect on the claim form (denialcodes) or explain why DHS is manually reviewing theclaim (suspended codes.) The description of each code isfound on the “Explanation of Edits Set This Cycle”page(s) at the end of the RA. These messages used inconjunction with the claim status notify you whathappened to your claim and if there are actions that needto be taken. Please note that there are several codes thatare for informational purposes only. These explanationcodes do not cause your claim to deny. For example, youmay see the code 9000 (Billed Amount Exceed AllowedAmount) setting with the status of “P” for paid on yourclaim. This is letting you know that the claim or claim linehas been paid and that the system has reduced thepayment to correspond to the Medical Assistance FeeSchedule. You do not need to take any action whenreceiving these informational related explanation codes.Please review the sample reconciliation method found inthe Remittance Advice section of each ProviderHandbook for information on setting up your ownaccounts receivable method.Indicates the status of the recipient as of the endingservice date of the period covered on an institutionalclaim.Identifies a diagnosis related grouping. The DRG code isused to determine the payment amount for hospitalinpatient claims.Code that identifies a specific accommodation or ancillaryservice. Revenue codes are established by CMS.General Assistance Deductible amount. This is the dollaramount for this claim that was applied to the GeneralAssistance deductible set for this client by DHS.The amount of recipient copayment deducted for theservice.Date the claim form was signed by the provider or thedate the claim was transmitted electronically.Total amount billed for the claim.First two digits identify the processing cycle. The fivedigits following the slash (/) identify the particular RAwithin the cycle. The RA number should be used whenmaking inquiries about the information contained on theRA Statement.MA 548 03/11

PROVIDER QUICK TIPSThe RA Summary Page(s) contains information summarizing all action taken on your claimsduring the processing cycle. See Sample Summary Page below. All items have been numberedand correspond with the matching definitions below and on the eigthth and ninth pages of thisQuickTip.Sample – Summary PageBDCMMA 548 03/11