clm104c22.pdf

 Loop usage within ASC X12 transactions and their implementation guides can be confusing. Care must be used to read the loop requirements in terms of the context or location within the transaction.    The usage designator of a loops beginning segment indicates the usage of the loop. Segments within a loop cannot be sent without the beginning segment of that loop.   If the first segment is required, the loop must occur at least once unless it is nested in a loop that is not being used. A note on the required first segment of a nested loop will indicate dependency on the higher -level loop.   If the first segment is Situational, there will be a Segment Note addressing use of the loop. Any required segments in l oops beginning with a Situational segment occur only when the loop is used.  Similarly, nested loops occur only when the higher -level loop is used.   Companion Documents for both Part A and Part B are available at:   http://www.cms.gov/ElectronicBillingEDITrans/30_CompanionGuides.asp#TopOfPage   50 - Standard Paper Remittance Advice  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  The Standard Paper Remittance (SPR) is the hard copy version of an ERA.  All A/B MACs and DME MACs must be capable of producing SPRs for providers who are unable or choose not to receive an ERA.  A/B MACs and DME MACs suppress distribution of SPRs if a provider is also receiving ERAs for more than 31 days (institutional providers) or 45 days (professional providers/suppliers) respectively.   50.1 - The Do Not Forward (DNF) Initiative  (Rev.: 4388; Issued: 09- 06-19; Effectiv e: 10 -07-19; Implementation: 10 -07-19)  As part of the Medicare DNF Initiative, A/B MACs and DME MACs must use return service requested envelopes for mailing all hardcopy remittance advices. When the post office returns a remittance advice due to an inco rrect address, follow the same procedures followed for returned checks; that is:    Flag the provider DNF; A/B MAC staff must notify the provider enrollment area, and DME MACs must notify the National Supplier Clearing House (NSC);    Cease generating any f urther payments or remittance advice to that provider or supplier until they furnish a new address that is verified; and    When the provider returns a new address, MACs remove the DNF flag after the address has been verified, and pay the provider any funds  still being held due to a DNF flag. MACs must also reissue any remittance that has been held as well.   NOTE: Previously, CMS required corrections only to the pay to address. However, with the implementation of this new initiative, CMS requires correctio ns to all addresses before the MAC can remove the DNF flag and begin paying the provider or supplier again. Therefore, do not release any payments to DNF providers until the provider enrollment area or the National Supplier Clearinghouse (NSC) has verified and updated all addresses for that providers location. MACs must initially publish the requirement that providers must notify the A/B MAC or NSC of any changes of address, both on their Web sites and in their next regularly scheduled bulletins. MACs must  continue to remind suppliers and providers of this requirement in their bulletins at least yearly thereafter.  See Chapter 1 for additional information pertaining to the DNF initiative.   60 - Remittance Advice Codes  (Rev. 11427; Issued: 05- 20-22; Effective: 01 -01-23; Implementation: 01- 03-23) NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document  the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer sat isfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. D ue to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is requir ed, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.   The remittance advice provides explanation of any adjustment(s ) made to the payment. The difference between the submitted charge and the actual payment must be accounted for in order for the ASC X12 835 to balance. The term adjustment may mean any of the following:    denied    zero payment    partial payment    reduced payment    penalty applied    additional payment    supplemental payment   Group Codes, Claim Adjustment Reason Codes and Remittance Advice Remark Codes are used to explain adjustments at the claim or service line level. Provider Level Adjustment or PLB Reason Codes are used to explain any adjustment at the provider level.     60.1  Group Codes  (Rev. 2843, Issued: 12- 27-13, Effective: 01- 28-14, Implementation: 01- 28-14)  A group code is a code identifying the general category of payment adjustment. A group code must always be used in conjunction with a claim adjustment reason code to show liability for amounts not covered by Medicare for a claim or service.  MACs do not ha ve discretion to omit appropriate codes and messages. MACs must use appropriate group, claim adjustment reason, and remittance advice remark codes to communicate clearly why an amount is not covered by Medicare and who is financially responsible for that amount. Valid Group Codes for use on Medicare remittance advice:    CO -  Contractual Obligations. This group code shall be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these  adjustments are considered a write off for the provider and are not billed to the patient.   OA -  Other Adjustments. This group code shall be used when no other group code applies to the adjustment.    PR - Patient Responsibility. This group code shall be us ed when the adjustment represent an amount that may be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.  60.2  Claim Adjustment Reason Codes (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08 -31-2020)   Claim Adjustment Reason Codes (CARCs) are used on the Medicare electronic and paper remittance advice, and Coordination of Benefit (COB) claim transaction.  The Claim Adjustment Status and Reason Code Maintenance Committee main tains this code set.  A new code may not be added, and the indicated wording may not be modified without the approval of this committee.  These codes were developed for use by all U.S. health payers. As a result, they are generic, and there are a number of  codes that do not apply to Medicare. This code set is updated three times a year.  MACs shall use only most current valid codes in ERA, SPR, and COB claim transactions.  Any reference to procedures or services mentioned in the reason codes apply equally t o products, drugs, supplies or equipment.  References to prescriptions also include certificates of medical necessity (CMNs).   These reason codes explain the reasons for any financial adjustments, such as denials, reductions or increases in payment.  These  codes may be used at the service or claim level, as appropriate.  Current ASC X12 835 structures only allow one reason code to explain any one specific adjustment amount.  There are basic criteria that the Claim Adjustment Status and Reason Code Maintenan ce Committee considers when evaluating requests for new claim adjustment reason codes:    Can the information be conveyed by the use or modification of an existing reason code?    Is the information available elsewhere in the ASC X12 835?    Will the addition of  the new reason code make any significant difference in the action taken by the provider who receives the message?   The list of Claim Adjustment Reason Codes can be found at the official Washington Publishing Company website.   The updated list is publishe d three times a year after the committee meets before the ASC X12 trimester meeting in the months of January/February, May/June, and September/October. MACs must make sure that they are using the latest approved claim adjustment reason codes in ERA, SPR and COB transaction by implementing necessary code changes as instructed in the Recurring Code Update Change Requests (CRs) or any other CMS instruction and/or downloading the list from the WPC website after each update.  The Shared System Maintainers shall make sure that a deactivated code (either reason or remark) is not allowed to be used in any original business message, but is allowed and processed when reported in derivative business messages.  Code deactivation may be implemented prior to the stop date  posted at the WPC web site to follow Medicare release schedule.  SSMs shall implement deactivation on the earlier date if the implementation date in the recurring code update CR is different than the stop date posted at the WPC Web site.   The MACs are res ponsible for entering claim adjustment reason code updates to their shared system and entry of parameters for shared system use to determine how and when particular codes are to be reported in remittance advice and coordination of benefits transactions.  I n most cases, reason and remark codes reported in remittance advice transactions are mapped to alternate codes used by a shared system.  These shared system codes may exceed the number of the reason and remark codes approved for reporting in a remittance advice transaction.  A particular ASC X12 835 reason or remark code might be mapped to one or more shared system codes, or vice versa, making it difficult for a MAC to determine each of the internal codes that may be impacted by remark or reason code modifi cation, retirement, or addition.  Shared systems must provide a crosswalk between the reason and remark codes to the shared system internal codes so that a MAC can easily locate and update each internal code that may be impacted by a remittance advice reas on/remark code change to eliminate the need for lengthy and error prone manual MAC searches to identify each affected internal code.  Shared systems must also make sure that 5 -position remark codes can be accommodated at both the claim and service level fo r ASC X12 835 version 4010 onwards.   The effective date of programming for use of new or modified reason/remark codes applicable to Medicare is the earlier of the date specified in the CMS manual transmittal or CMS Recurring Code Update change request or the Medicare Claims Processing Manual transmittal that implemented a policy change that led to the issuance of the new or modified code.  MACs must notify providers of the new and/or modified codes and their meanings in a provider bulletin or other instructional release prior to issuance of remittance advice transactions that include these changes.  Some CARCs are so generic that the reason for adjustment cannot be communicated clearly without at least one remark code.  These CARCs have a note added to the text for identification.  A/B MACs and DME MACs must use at least one appropriate remark code when using one of these CARCs.     60.3  Remittance Advice Remark Codes  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  Remittance Advice Remark Codes (RARCs) are used in  a remittance advice to further explain an adjustment or relay informational messages that cannot be expressed with a claim adjustment reason code.  Remark codes are maintained by CMS, but may be used by any health plan when they apply.  MACs must report a ppropriate remark code(s) that apply.  There is another type of remark codes that does not add supplemental explanation for a specific adjustment but provides general adjudication information. These Informational remark codes start with the word Alert and can be reported without Group and Claim Adjustment Reason Code.  An example of an Informational RARC would be:   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.