Remittance Advice Interpretation

Enclosed is information to assist you with understanding the various sections of your Remittance Advice (RA). We have listed the names and descriptions of all sections of the RA. 

BANNER PAGE — The first page of the Remittance Advice (RA) is the “Banner Page”. Official Notices from the Department of Human Services and/or announcements from EDS may appear on this page.

• Providers should read these messages carefully!
• Banner messages can be customized by provider type
• This is the most timely, efficient way to relay information

PAID CLAIMS (HCFA 1500) — This section of the RA reports new day, non-Crossover paid claims. A summary of the number of claims paid and the total dollar amount paid for the current payment period can be found on the last page of the Paid Claims section. 

PAID CLAIMS (PROFESSIONAL CROSSOVER) — This section of the RA reports paid Crossover (X-Over) claims. A summary of the number of X-Over claims paid and the total dollar amount paid for the current payment period is found on the last page of the Paid Claims/Professional X-Over section. The last page of this section also reports the combined total number of X-over and non-X-Over paid claims and the total dollar.

DENIED CLAIMS (HCFA 1500) — This section of the RA reports denied claims. Three digit EOB (Explanation of Benefits) codes along with the HIPAA related codes, also called ‘Finalized Claim Codes’. The first three codes provide the explanation of the denial reason. A list of applicable Finalized Claim Codes with detailed information is provided on the last page of the RA, the Earnings Data page. 

SUSPENDED CLAIMS (HCFA 1500) — This section of the RA provides the status of suspended claims. Three digit Suspended Claim Codes, also known as ‘Error Status Codes’, are provided to explain the reason for the claims suspended status

PAID ADJUSTED CLAIMS — This section of the RA delineates the status of paid adjusted claims. 

• An adjusted claim is a claim that was previously paid and appeared in Paid Claims section of your RA (even if the amount paid was $0.00) and now requires changes and/or reprocessing to accurately reflect the services provided
• The Adjustment Process requires the original claim to be recouped (withheld). The claim is reprocessed in the SAME financial cycle. If paid, the Net Adjustment Amount will reflect the difference (+/-) between the original claim and the adjusted version
• The original claim 1, which shows how the claim originally processed, is displayed before the adjusted claim 2. The adjusted version shows the claim as processed following changes and/or reprocessing.
• The flower box at the end of the Adjusted Claims section 3, reports the number of original claims and the total original paid amount of the claims prior to being adjusted
• And the original paid claim amount will be recouped.

DENIED ADJUSTED CLAIMS — This section of the RA reports the previously paid claims that were denied when reprocessed as part of the Adjustment Process.

• The Adjustment Process requires the original claim to be recouped (withheld). The claim is reprocessed in the SAME financial cycle. If the claim denies, no new payment will be made to the provider and the original paid claim amount will be recouped.
• The first flower box 1, on the bottom of the last page of the Denied Adjusted Claims section shows the total dollar amount the claims originally paid prior to being reprocessed as part of the adjustment process.
• The second flower box 2, on the bottom of the last page of the Denied Adjusted Claims section shows the dollar amount related to original paid claims that either paid or denied when reprocessed in the adjustment process.
• Examples of the denied adjusted claims are outlined on the following page.

SUSPENDED ADJUSTED CLAIMS — This section of the RA provides the status of adjusted claims that suspended when reprocessed. Recoupment to the original claim will not be applied (withheld) until the claim has been finalized (either paid or denied). Providers should not resubmit suspended adjustment claims until the claim is in a finalized status.

FINANCIAL ITEMS — The Financial Items section of the RA reports financial activities. 

Voids, Refunds and Specific Claim Recoupments

Void: A financial transaction that is the result of an EDS check returned from the provider resulting in the ‘voiding’ of all claims associated with the check.
Refund: A financial transaction that is the result of a provider writing and sending a check to EDS. Refund checks may be claim specific or non-claim specific. Claim related refunds result in the reversal of payment of a specific claim(s).
Specific Claim Recoupments: A financial transaction that is the result of a request to reverse payment of a claim with no subsequent processing.

Note: The above mentioned financial transactions will ONLY appear in the Financial Items section of the RA.

Miscellaneous Payout: An interim payment generated through either the system or manually.
The following are the reason codes pertaining to these types of financial transactions:
057   Provider - Miscellaneous Payout (system payout / interim payment)
040   DHS Adjust - Miscellaneous or unspecified Error (manual payout)

Miscellaneous payout amounts that are “set up” to be recovered will appear with the following reason code in the Financial Items section of the RA:
061   Recoupment of Provider Payout

Note: Miscellaneous payout and recovery transactions will only appear in the Financial Items section of the RA.

Adjustments: A transaction that is the result of the take back (recoup) of a paid claim as part of the adjustment process.
Note: A specific code will be provided explaining the reason for the set up of this type of financial transaction.

All of the above mentioned financial transactions, with the exception of refunds, will appear again on the same or a future RA indicating that funds have been applied to the original set up amount. The amount being applied to the set up amount is indicated in the TXN AMT column on the Financial Items page of the RA. If funds are applied to a portion of the set up amount, the outstanding / remaining balance will appear in the BAL AMT column. The balance amount must be zero for the transactions to be considered complete. If not, the outstanding transaction(s) will be carried over to the next financial cycle where there may be additional funds to apply towards the balance amount.

EARNINGS DATA — This section contains a financial summary for the current pay period that is listed for the RA date (in example 12/19/97); and year-to-date information. All finalized and suspended messages for the current RA are also listed. The information provided in each category is shown below. 

• No. of Claims Processed: Total number of paid and denied claims (new day, x-over, and adjusted)
• Claims Paid Amount: Total dollar amount processed (new day, x-over, and adjusted)
• System Payout Amount: Dollar amount paid out to the provider through an automated process
• Recoup Amount Withheld: Dollar amount withheld from the provider as a result of system payout, manual payout, or claim adjustments (mass/single adjustments (+) any claim specific recoupments)
• Payment Amount: Total dollar amount paid to the provider. This amount is determined by adding the ‘Claims Paid Amount’, plus (+) the ‘System Payout Amount’, minus (-) the ‘Recoupment Amount Withheld’
• Manual Payout Amount: Dollar amount paid out to a provider through a manual process
• Net Earnings: Claims paid amount, plus system payout, plus manual payout, minus recoupment, minus credit items
• Credit Items: Dollar amount related to any credit items. These include State void transactions, and refund transactions
• Net Adjustment Amount: Total net adjustment amount from the adjusted claims processed (both adjusted paid and adjusted denied). This is a result of all positive and negative adjusted claims plus any denied adjusted claims. The total net adjustment may result in a positive or a negative.
  Note:  This does not include claim specific recoupments.
• Net 1099 Adjust: An adjustment to the provider’s 1099 to offset a previous financial transaction to accurately reflect taxable income.

Steps To Ensure Correct Processing of Your Paper Claims

General Billing:

• Ensure that all data is entered in the appropriate box

• Ensure that data is contained within the border of the box

• Ensure that stamps do not obscure vital information

For billing coordination of benefit claims:

• Include the explanation of benefits (EOB) from the primary insurance

• Provide the three digit carrier code for the primary insurance

• Select YES in Box 11D

• Block 28 should contain the billed amount on the EOB

• Block 29 should contain the paid amount from the primary insurer

• The total charge in Block 29 must equal the sum of the detail lines contained in 24F