This section summarizes the Explanation of Medicare Benefit statements for both you and a beneficiary. It also contains our most current revision to the Post Payment Review department's correspondence.
17.2 Standard Paper Remittance
The Health Care Financing Administration (HCFA) has mandated a standardized explanation of benefits used by all Medicare carriers. This explanation is called the Standard Paper Remittance (SPR). This chapter includes a guide to assist all providers and billers in understanding the new format. The guide provides a description of all fields on the SPR, an explanation of offset details, and information on payment and denial codes.
In addition,HGSAdministrators has an interactive SPR on its website, www.hgsa.com, which allows access to the field definitions with point and click convenience.
a. Field Descriptions
Perf Prov: This field displays the beneficiary's name, the billing provider number, the rendering provider number, the patient responsibility heading, and some message codes. When checking the reason for denial make sure not to overlook this code. There may be remarks also in this field. These remark codes are important to incomplete claim rejections. For example: REM: M76. This code needs to be defined in the glossary.
Serv Date: This field provides the service from and to dates as well as the patient's responsibility.
POS: The place of service field contains a two digit number that references where the services were rendered.
NOS: The number of service field shows how many services were billed per procedure code.
Proc: The procedure code is located in this column as well as the patients Health Insurance Claim number (HIC) or the Medicare number.
MODS: If any modifiers were billed, they will be located in this field.
Billed: This field also contains the billed amount per procedure. If the patient account number is reported on the claim, Medicare will display that number in this field.
Allowed: This column displays the allowed amounts per procedure. This amount is based on the Medicare Fee Schedule.
Deduct: If any deductible is applied the amount will show in this field. The Internal Control Number (ICN) will also appear in this column.
Coins: This is the coinsurance field. The amount of the beneficiary's coinsurance, 20% of the allowed amount, will be displayed here.
Group Reason Code (GRP/RC): Group codes represent the financially responsible party. Reason codes explain denials and payments. These combinations of codes are defined in the glossary at the bottom of the Standard Provider Remittance. An on line reference is available for your convenience, as well as a full listing in chapter 21.
Grp/RC-Amt: This column contains the type of assignment (ASG). A "Y" indicator shows the provider accepted assignment. A "N" indicator shows a non-assigned claim. Under the assignment indicator are the non-covered service amounts. These amounts will equal the difference between the billed amount and allowed amount. The last field in this column is a total of the non-covered amounts.
Prov. Pd: The amount paid per procedure is displayed in this field. Also the total amount paid on this claim is shown in this column. The claim total reported is the net payment. The MOA (Medicare outpatient adjudication remarks) code is the heading. This code does not display any adjustments or reasons. The codes following this heading explain the outcome of the claim, and also need to be defined in the glossary. There is also a full listing in chapter 21.
Total Claims: Number of claims displayed on the SPR.
Total Billed: Total amount billed on the SPR.
Total Allowed: Total allowed amount on the SPR. This amount is based on Medicare's Fee Schedule.
Total Deduct: The total amount of the deductible applied on the SPR.
Total Coins: Total amount of coinsurance on the SPR.
Total Grp/RC-Amt: Total amount of non-covered services. This is the difference between the total billed amount and the total allowed amount.
Total Prov. Pd: The total amount paid on the SPR. This should be the check amount if no adjustments were made.
Total Prev Pd: This amount shows previously paid amounts that are credited on this SPR. (i.e. advance payments)
Total Paid to Bene: Total amount paid to patients.
Total Int: Total interest paid on this SPR.
Total MSP: Total amount paid towards Medicare secondary payer claims.
Total Offset: This amount indicates offsets, withheld to settle monies owed to Medicare, or any money added or subtracted from the total provider paid. If an amount is present, reference the offset details below IN, OF, LF to understand the reason of the offset. (i.e. FCN - financial control numbers, patients accounts)
Total Other Adjustments: This field displays other claim level adjustments that apply to this SPR.
Amount of Check: This field shows the amount of the check the provider will be receiving.
Offset Details: This field displays the reason for the offset. A two letter code is shown.
IN = Interest applied
LF = Late filing reduction
OF = Offset amount
FCN: The codes need to be defined in the glossary. This will give the financial control number of the account receivable department.
HIC: The field displays the health insurance claim number of the patient who caused the offset.
Act/Name: This field displays the provider's patient account number and name of patient.
Amount: The total amount applied.
Glossary: This is a guide to all the reason codes. Use remarks and codes in the claim detail and summary portions of SPR to determine the outcome of the claim.
For an example of the Standard Paper Remittance
17.3 Beneficiary Explanation of Medicare Benefits (EOMB)
The Explanation of Medicare Benefits (EOMB) is used to notify Medicare beneficiaries of action taken on carrier processed claims. The EOMB provides the beneficiary with a record of services received and the status of any Part B deductible. The EOMB also informs beneficiaries of appeal rights.
The EOMB is specifically designed as a notice to beneficiaries. It includes data for assigned claims and nonassigned claims.
Page one of each EOMB contains the following information:
Disclaimer ("THIS IS NOT A
BILL"), title of notice ("Explanation of Your Medicare Part B
Area one of the EOMB contains the following:
Beneficiary name and mailing address
Beneficiary Medicare number, SSA# plus the alpha numeric,
Assignment status, a statement indicating whether the billing provider accepted assignment or not on the claim, and
a summary block containing the following:
—Charges billed by the provider ("Total charges")
—Medicare approved amount ("Total Medicare approved")
—Medicare payment ("We paid provider")
—The beneficiary's responsibility ("Your total responsibility")
The second area, or box, contains the following elements:
Provider name(s) and address(es); the name and address of the provider includes provider/supplier/laboratory name (group name, if a clinic), street address, city, state, and zip code ("BILL SUBMITTED BY").
Date of service ("Dates")
Service or line item detail ("Services and Service Codes")
Charges billed by the provider ("Charges")
Medicare approved amounts ("Medicare Approved")
Alphabetic note cards ("See Notes Below")
The third area of the first page contains notes about the claim and specific notes about the line items indicating reasons for payment or non-payment.
Area four of the EOMB displays the mathematical computations from which the dollar amounts displayed in the summary box of Area I are derived.
Area five of the EOMB provides the name and telephone number and physical address of the carrier. It also gives the deadline to appeal a claim.
The check summary section, the last page of the EOMB, summarizes Medicare's payment amount when multiple non-assigned claims finish processing at the same time. The check summary contains the following information:
Disclaimer ("This is Not a Bill")
Beneficiary name and mailing address
Beneficiary Medicare number
Summary block containing:
—Dollar amount per control number
—Total check amount
The back of the EOMB lists important information about Medicare Part B Benefits. This section is entitled "Important Information You Should Know About Your Medicare Part B Benefits".
a.Beneficiary Explanation of Medicare Benefits example
17.4 System Generated Correspondence
With our commitment to serving Medicare beneficiaries and health care professionals, HGSAdministrators has enhanced the format of all system generated correspondence. This new format has been designed to ease your understanding of any correspondence which you may receive in the future.
|Dr. John Smith||Dec. 11, 1998|
|2222 Green Lane||In Any Inquiry Refer To|
|Enola, PA 17025||8798313500000|
|Health Insurance Claim Number|
|999 99 9999A|
|Internal Control Number|
|July 03, 1997|
|Services Provided by|
|Dr. John Smith|
|Services Provided to|
Dear Dr. Smith:
This letter is in response to an appeal received on January 1, 1999. I completed an independent review of the claim in question. The review involved the office visit performed for the reported condition.Determination: (Our review determination would be placed in this area.)
Appeal Rights: (Appeal rights will now be found on the back of the letter, when they apply.)
If you do not agree with our determination, you may take further action. Please refer to item number 3 on the back of this letter. It will explain the option that applies in your case.
If you have any questions about this letter, please feel free to contact our customer service office. If you are in Pennsylvania, the phone number is 1/800/382/1274. Please note, the phone number only works when calling from within Pennsylvania.
You can also write to our office with your concerns at the address listed below. We will be more than happy to assist you. Please be sure to reference the case number listed in the upper right hand corner of this letter.
P O Box 890413
Camp Hill, PA 17089-0413
Each state has its own information counseling and assistance program. The number for the Pennsylvania office is 1-800-783-7067. If you do not reside in Pennsylvania and wish to contact your state agency, please refer to The Medicare Handbook for a complete listing of state agencies.
a.1 Appeal Rights
To obtain copies of Medicare laws and guidelines that apply to these services, write to: Freedom of Information Act/Medicare, P.O. Box 890700, Camp Hill, PA 1708-0700.
1. APPEALS RIGHTS-BENEFICIARY
If you do not agree with how your claim was processed, you may request a review. This must be done within six (6) months of the date of this notice. Most reviews must be requested in writing. However, certain cases may be handled over the phone. To find out more, you may call 1-800-382-1274 (Pennsylvania). If you are call from outside of Pennsylvania, you must call 1-800-746-5680. If you would prefer to write, our address is: HGSAdministrators, Post Payment Review Department, P. O. Box 890413, Camp Hill, PA 17089-0413.
If you want help with your appeal, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyers referral services, that can help you find a lawyer. There are also groups, such as legal aide services, who will give you free legal services if you qualify.
2. APPEAL RIGHTS-PROVIDER
If you do not agree with how the claim processed, you may request a review. Most reviews, with the exception of medical necessity, can be handled over the phone by calling the Telephone Appeals Program (TAP) at (717) 730-1455. You may also write to: HGSAdministrators, Post Payment Review Department, P. O. Box 890413, Camp Hill, PA 17089-0413. All reviews must be requested within six (6) months of the date of this notice. Electronic appeal requests may be submitted via MPIplus. For more information on electronic options, contact Medicare Electronic Services (MES) at (717) 763-6722.
Effective August 1, 1999, TAP will nolonger accept telephone appeals for provider billing errors involving the omission of claim data. Your office will have two options for denials due to the omission of claim data:
1. Correct the
claim and resubmit for procesing.
The appeals rights on the initial claim denial are still preserved.
2. Exercise the
appeal rights associated with the initial claim denial.
This appeal request must be in writing and must include the medical documentation to support the additional claim data (i.e., notes or records showing request for repeat procedure, records showing correct diagnosis, etc.).
errors cause claim denials due to the omission of supporting claim data. These
duplicate denials where the repeat procedure code modifier should have been billed
medical necessity denials where the incorrect diagnosis code was billed
rebundling denials where a different site of service modifier should have been billed
Claims that are denied due to the omission of supporting claim data can easily be corrected by resubmitting them with the additional data (i.e., modifier, correct diagnosis code, etc.).
3. APPEAL RIGHTS AFTER OUR REVIEW DECISION-BENEFICIARY AND PROVIDER
If you do not agree with our review decision, you may request a hearing if both of the following conditions are met:
A. There is $100.00 or more in question. (You can combine services that have been reviewed within the last six months to meet this amount.)
B. The fair hearing is requested within six months from the date of the Medicare Part B Review.
If you would like to pursue a fair hearing, sign and date this letter and select a type of fair hearing. Please mail the entire letter along with all of the facts that could assist with your case to the following address: Medicare Fair Hearing Office, P. O. Box 890050, Camp Hill, PA 17089-0050
Choose the type of hearing you wish to have by checking one of the following types:
Telephone hearing - This may be the
most convenient option for you.
In-person hearing - This lets you attend and share in the process.
Note: You may have someone attend the hearing for you. Be sure to complete an Appointment of Representative form which are be obtained from your local Social Security office.
On-the-record hearing - The judgement
is based on the facts in the file. You do not have to attend.
In all three types of hearings, the hearing will be held by an impartial hearing officer and you will receive notice of the outcome.