clm104c22.pdf

Medicare Claims Processing Manual  Chapter 22 - Remittance Advice   Table of Contents  (Rev. 11427, 05- 20-22)  Transmittals for Chapter 22  10 - Background  20 - General  Remittance  Completion  Requirements  30 - Remittance Balancing  40 - Electronic Remittance Advice  - ERA or ASC  X12  835 40.1 -  ASC  X12  835 40.2 -  Generating  an ERA  if Required  Data is Missing  or Invalid  40.3 -  Electronic Remittance Advice  Data Sent  to Banks  40.4 -  Medicare Standard  Electronic PC -Print  Software  for Institutional  Providers  40.5 -  Medicare Remit  Easy  Print  Software for Professional  Providers  and Suppliers  40.6 -  ASC  X12  835 Implementation  Guide  (IG)  or Technical  Report  3 (TR3) 50 - Standard Paper  Remittance Advice 50.1 -  The Do  Not Forward  (DNF)  Initiative  60 - Remittance Advice  Codes  60.1 -  Group  Codes  60.2 -  Claim Adjustment  Reason  Codes  60.3 -  Remittance Advice  Remark Codes  60.4 -  Requests  for Additional C odes  80 - The Council for Affordable Quality Hea lthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Mandated Operating Rule s 80.1 -  Health Care Claim Payment/Advice (835) Infrastructure Rule  80.1.1 -  Version X12/50 10X221 Companion Guide  80.2 -  Uniform Use of CARCs and RARCs Rule  80.3 -  EFT Enrollment Data Rule  80.4 -  ERA Enrollment Form    10 - Background  (Rev. 3288, Issued: 07 -02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  The A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) send to providers, physicians, and suppliers, as a companion to claim payments, a notice of payment, referred to as the Remittance Advice (RA).  RAs explain the payment and any adjustment(s) made during claim adjudication.  For each claim or line item payment, and/or adjustment, there is an associated remittance advice item.  Adjustment is defined as:   denied   zero payment   partial payment   reduced payment   penalty applied   additional payment   supplemental payment   Payments and/or adjustments for multiple claims can be reported on one transmission of the remittance advice.  RA notices can be produced and transferred in either paper or electronic format.   The A/B MACs and DME MACs also send informational RAs to nonparticipating physicians, suppliers, and non- physician practitioners billing non- assigned claims (billing  and receiving payments from beneficiaries instead of accepting direct Medicare payments), unless the beneficiary or the provider requests that the remittance advice be suppressed.  An informational RA is identical to other RAs, but must carry a standard message to notify providers that they do not have appeal rights beyond those afforded when limitation on liability (rules regulating the amount of liability that an entity can accrue because of medical services which are not covered by Medicare (see Pub. 10 0-04, chapter 30) applies.   The MACs are allowed to charge up to a maximum of $25 for generating and mailing, if applicable, duplicate remittance advice (both electronic and paper) to recoup costs when generated at the request of a provider or any entity w orking on behalf of the provider.  Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) administrative provisions, the Secretary of Health and Human Services has adopted ASC X12  Health Care Claim Payment/Advice (835) version 5010A 1 to be the standard effective from January 1, 2012.  The CMS has implemented the new HIPAA standard following the ASC X12 Technical Report 3 (TR3) for transaction 835 version 5010A1, and requires the use of this format exclusively for Electronic Remittanc e Advices (ERAs) on or after full implementation. CMS has also established a policy that the paper formats shall mirror the ERAs as much as possible, and all MACs shall use the paper formats  Standard Paper Remit or SPR -  established by CMS.   Provider Ide ntification:  Medicare requires claims to contain National Provider Identifiers (NPIs) to be accepted for adjudication.  NPIs received on the claims are cross walked to Medicare assigned legacy numbers for adjudication.  Adjudication is based on each unique combination of NPI/legacy number if there is no one -to-one relationship between the two.  Any ERA or SPR sent after version 5010A1 has been implemented will have one of the three provider identifications: (1)Federal Taxpayers Identification Number; (2) Centers for Medicare and Medicaid Services PlanID; or (3) Centers for Medicare & Medicaid Services National Provider Identifier (NPI) as the provider ID instead of any Medicare assigned provider number at the provider level.  NPIs will be sent as the provi der identification at the claim level.  As the Rendering Provider Identifier at the service line level, any one of the following identifiers:  (1) Centers for Medicare & Medicaid Services National Provider Identifier; (2) Social Security Number; (3) Federa l Tax Payers Identification Number; or (4) Medicare Provider Number;  will be sent.   20 - General Remittance Completion Requirements  (Rev. 2843, Issued: 12- 27-13, Effective: 01- 28-14, Implementation: 01- 28-14)  The following general field completion and calculation rules apply to both paper and electronic versions of the remittance advice, except as otherwise noted. See the current implementation guide for specific requirements:  Any adjustment applied to the submitted charge and/or units must be reported in the claim and/or service adjustment segments with the appropriate group, reason, and remark codes explaining the adjustments. Every provider level adjustment must likewise be reported in the provider level adjustment section of the remittance advice. I npatient RAs do not report service line adjustment data; only summary claim level adjustment information is reported.    The computed field Net reported in the Standard Paper Remittance (SPR) notice must include ProvPd (Calculated Payment to Provider, CLP04 in the ASC X12 835) and interest, late filing charges and previously paid amounts.   MACs report only one crossover payer name on both the ERA and SPR, even if coordination of benefits (COB) information is sent to more than one payer. The current HIPA A compliant version of the ASC X12 835 does not have the capacity to report more than one crossover carrier, and the SPR mirrors the ASC X12 835.   The check amount is the sum of all claim -level payments, including claims and service- level adjustments, less  any provider level adjustments.    Positive adjustment amounts reduce the amount of the payment and negative adjustment amounts increase it.    The MAC does not issue an RA for a voided or cancelled claim. It issues an RA for the adjusted claim with Previous ly Paid (CLP04 in the ASC X12 835) showing the amount paid for the voided claim.   The shared system maintainers and contractors must make sure that the HIPAA transactions 835 and 837 COB balance after a system change resulting from a policy change that ma y or may not be directly related to Electronic Data Interchange (EDI).   30 - Remittance Balancing  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  For Medicare the principles of remittance balancing are the same for both paper and electronic remittance formats.  Balancing requires that the total paid amount is equal to the total submitted charges plus or minus payment adjustments for a single ASC X12 835 remittance in accordance with the rules of the standard ASC X12 835 format.  Refer to Front Matter Section 1.10.2.1 for Balancing in the ASC X12 835 version 5010 TR3.  Every HIPAA compliant ASC X12 835 transaction issued by a MAC must comply with the ASC X12 835 version 5010 TR3 requirements, i.e., these remittances must balance at the service, claim, and provider levels.  The flat files generated by the shared systems must be balanced at the line, claim, and provider level.  As a failsafe measure claim adjustment reason code121 and PLB reason code 90 may be used at the line, clai m, and provider level respectively to make sure that the ASC X12 835 is balanced.  Shared System generated reports must track the usage of these codes, and A/B MACs and DME MACs must work closely with the shared system maintainers and CMS to resolve the issues resulting in out of balance situations.   40 - Electronic Remittance Advice  - ERA or ASC X12 835 (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08- 31-2020)   Electronic Remittance Advice (ERA) transactions must be produced in the current HIPAA compliant ASC X12 835 version /5010.  Directions for version updates are posted when necessary in CMS Change Request (CR) instructions issued by CMS.  Refer to the official Washington Publishing Company website for implementation guides, record formats, and data dictionaries for the ASC X12 835  Shared systems maintainers must provide appropriate provider file structures and switching mechanisms so that MACs can select and generate the ASC X12 835 and/or the automated clearing house (ACH) format when electronic funds transfer (EFT) applies. See the implementation guides for further information on the abbreviated ASC X12 835 and use of the ASC X12 835 for EFT.   Changes to content and format of ERAs may not be made by individual MACs.  Change s will be made only by shared system maintainers, and then, only as directed by CMS.  40.1 - ASC X12 835 (Rev.: 4388; Issued: 09- 06-19; Effective: 10- 07-19; Implementation: 10 -07-19)  The ASC X12 835 is a variable -length record designed for wire transmissi on and is not suitable for use in application programs.  Therefore, shared systems generate a flat file version of the ASC X12 835.  MACs must translate that flat file into the variable length ASC X12 835 record for transmission to providers or their billi ng services or clearinghouse.  See Chapter 24 for technical information about transmission of the ASC X12 835.  The updated flat files are posted at:   https://w ww.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Remittance.html  Go to Downloads, and click on the file you want.   The MAC requirements are:    Send the remittance data directly to providers or their designated billing services or clearinghouses;    Provide sufficient security to protect beneficiaries privacy.  The MAC does not allow any party to view beneficiary information, unless authorized by specific instructions from CMS    Issue the remittance advice specifications and technical interface speci fications to all requesting providers within three weeks of their request.  Interface specifications must contain sufficient detail to enable a reasonably knowledgeable provider to interpret the RA, without the need to pay the MAC or an associated business  under the same corporate umbrella for supplemental services or software;    A/B MACs (A) allow Part A providers to receive a Standard Paper Remittance Advice (SPR) in addition to the ASC X12 835 during the first 31 days of receiving ERAs and during other te sting.  After that time, A/B MACs (A) do not send a hard copy version of the ASC X12 835, in addition to the electronic transmission, in production mode.  They should contact CMS if this requirement causes undue hardship for a particular provider, and a wa iver is needed;    A/B MACs and DME MACs must suppress the distribution of SPRs to those Part B providers//suppliers (or a billing agent, clearinghouse, or other entity receiving ERAs on behalf of those providers/suppliers) after 45 days of receiving both SP R and ERA formats.  In rare situations (e.g., natural or man- made disasters) exceptions to this policy may be allowed at the discretion of CMS.  A/B MACs and DME MACs should contact CMS if a waiver is needed;    MACs may release an ERA prior to the payment d ate, but never later than the payment date;    Ensure that their provider file accommodates the data necessary to affect EFT, either through use of the ACH or the ASC X12 835 format;    Pay the costs of transmitting EFT through their bank to the ACH.  Payees a re responsible for the telecommunications costs of EFT from the ACH to their bank, as well as the costs of receiving ASC X12 835 data once in production mode; and    Provide for sufficient back- up to allow for retransmission of garbled or misdirected transmissions.