General Remittance Completion Requirements

20 - General Remittance Completion Requirements (Rev. 2843, Issued: 12-27-13, Effective: 01-28-14, Implementation: 01-28-14) The following general field completion and calculation rules apply to both paper and electronic versions of the remittance advice, except as otherwise noted. See the current implementation guide for specific requirements: Any adjustment applied to the submitted charge and/or units must be reported in the claim and/or service adjustment segments with the appropriate group, reason, and remark codes explaining the adjustments. Every provider level adjustment must likewise be reported in the provider level adjustment section of the remittance advice. Inpatient RAs do not report service line adjustment data; only summary claim level adjustment information is reported. • The computed field “Net” reported in the Standard Paper Remittance (SPR) notice must include “ProvPd” (Calculated Payment to Provider, CLP04 in the ASC X12 835) and interest, late filing charges and previously paid amounts. • MACs report only one crossover payer name on both the ERA and SPR, even if coordination of benefits (COB) information is sent to more than one payer. The current HIPAA compliant version of the ASC X12 835 does not have the capacity to report more than one crossover carrier, and the SPR mirrors the ASC X12 835. • The check amount is the sum of all claim-level payments, including claims and service-level adjustments, less any provider level adjustments. • Positive adjustment amounts reduce the amount of the payment and negative adjustment amounts increase it. • The MAC does not issue an RA for a voided or cancelled claim. It issues an RA for the adjusted claim with “Previously Paid” (CLP04 in the ASC X12 835) showing the amount paid for the voided claim. • The shared system maintainers and contractors must make sure that the HIPAA transactions 835 and 837 COB balance after a system change resulting from a policy change that may or may not be directly related to Electronic Data Interchange (EDI).