Find-A-Code Focus Newsletter

Claims Processing and the Remittance Advice

October 13, 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
share
 

More Items in October 2014


To view more items select a month from our "Items by Month" list.

Or view documentation, coding and billing articles.

 

Poll

How likely are you to recommend Find-A-Code to a friend? 1 = not likely, 9 = very likely

News Items by Month
February 2022- 1
2021 - View
2020 - View
2019 - View
2018 - View
2017 - View
2016 - View
2015 - View
2014 - View
2013 - View
2012 - View
2011 - View
2010 - View
2009 - View
2008 - View
demo
request yours today
subscribe
start today
newsletter
free subscription

Thank you for choosing Find-A-Code, please Sign In to remove ads.