Claims Processing and the Remittance Advice

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
October 9th, 2014

After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. It features valid codes and specific values that make up the claim payment.

Some of these codes may identify adjustments, which refer to any changes that relate to how a claim is paid differently from the original billing. There are seven general types of adjustments:

1. Denied claim;

2. Zero payment;

3. Partial payment;

4. Reduced payment;

5. Penalty applied;

6. Additional payment; and

7. Supplemental payment.

Both assigned and non-assigned claims may be returned as unprocessable before a reimbursement decision is made if they contain claim errors (for example, incomplete or invalid information). You will receive a letter of explanation or a RA that provides information on claim errors. After the claim has been corrected, you must resubmit it as a new claim within the timely filing period. A claim that has been returned as unprocessable may not be appealed. You may appeal initial claim determinations, including denials, if you are dissatisfied with the claim determination and file a timely appeal request that contains the necessary information needed to process the request. If a denial is due to a minor error or omission you made in filing a claim, you may request a reopening to correct such clerical errors.

A reopening is separate and distinct from the appeals process. After the claim has been corrected, you must resubmit it within the timely filing period.

 

CMS.gov Claims processing

References:

Claims Processing and the Remittance Advice. (2014, October 9). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/claims-processing-and-the-remittance-advice-2259.html

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