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You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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Interactive Medicare Standard Paper Remittance (SPR) Advice

Interactive Medicare Standard Paper Remittance (SPR) Advice

The Medicare Remittance Advice (RA) is a notice sent to home health and hospice providers explaining how billing transactions are processed (paid, rejected, or denied). Billing transactions include final claims, adjustments, and canceled, denied, or rejected claims as well as Requests for Anticipated Payments (RAPs). SPRs are not provided if the HH&H has received the Electronic Remittance Advice (ERA) for more than 30 days. However, providers who have registered for myCGS (the CGS Web portal) are able to view and print standard paper remittances. The following additional resources are available on the Centers for Medicare & Medicare Services (CMS) website.

This interactive guide provides an overview of the SPR Advice. Select the section (below) that you wish to view. As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the fieldto view more detailed information.

The SPR includes two sections:

  • All Claims (AC) page(s) show information for each individual claim (not the individual charges on the claim). Claims will be listed on separate pages depending on whether the services apply to Medicare Part A or Part B.
  • Summary page includes information that encompasses all the claims included in the AC section.¬†


All Claims (AC) Page

The All Claims (AC) page includes information for each individual claim (not the individual charges on the claim). Claims will be listed on separate pages depending on whether the services apply to Medicare Part A or Part B.

As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the field to view more detailed information.

Medicare Administrative Contractor (MAC) Information
General information about CGS, your Medicare Administrative Contractor (MAC) who processed the claims and distributed the SPR. This information appears on the top of every page.

Provider Information
General information about the Medicare provider, which includes the provider's National Provider Identifier (NPI), name, and address.

Miscellaneous Information
The section of the SPR will identify whether the claims listed apply to Medicare Part A or Part B. Claims for Part A and Part B will appear on separate pages of the SPR. This section also provides the date the claims were paid, a unique SPR number (REMIT#), and the page number.

Patient Name
Last name, first name (or first initial) and middle initial (if available) of the beneficiary for whom the billing transaction was processed. Billing transactions will display in alphabetical order by the beneficiary's last name.

 

PATIENT CNTRL NUMBER
Patient control number that was submitted on the billing transaction.

Claim Adjustment Reason Codes (CARCs) provide information about an adjustment and explain why a billing transaction or service line was paid differently than it was billed. A list of the latest codes is available at http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/.

  • CARC 45 will display on home health final claims subject to the outlier limitation.
  • CARC 253 indicates a reduction in payment due to sequestration

Remittance Advice Remark Codes (RARCs) provides further explanation of an adjustment already described by the code in the RC field. It is also used to relay informational messages. A list of the latest codes is available at: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes/

The Diagnosis Related Group (DRG) number assigned to the billing transaction. Not applicable to home health and hospice billing transactions.

The outlier payment that was made in addition to the DRG payment (if applicable). Not applicable to home health and hospice billing transactions.

The coinsurance amount for which the beneficiary is responsible. Applicable to home health outpatient therapy billing transactions (34X type of bill).

The dollar amount that the provider owes the beneficiary for overpaid deductible and coinsurance. Not applicable to home health and hospice billing transactions.

An adjustment resulting from a contractual agreement between the payer and payee. This amount reflects the difference between the billed amount and the net reimbursement, minus any other deductions (e.g., sequestration).

Beneficiary's Medicare ID number for whom the billing transaction was processed.

 

Internal Control Number (ICN), also referred to as the Document Control Number (DCN) is a unique number assigned to the billing transaction when received by CGS.

 

An outlier code indicates a cost outlier was paid to a hospital provider.

The dollar amount of the funds Medicare pays for 'new technology' drugs and devices.

The dollar amount of Medicare covered charges.

The End-Stage Renal Disease (ESRD) Network Reduction amount. Not applicable to home health and hospice billing transactions.

The dollar amount for which the patient is responsible.

The beginning and ending dates on the processed billing transaction.

The beginning and ending dates on the processed billing transaction.

 

The Type of Bill (TOB) of the billing transaction (e.g., final claim, adjustment, canceled, denied, or rejected claim, and Request for Anticipated Payment (RAP).)

The physician's professional component billed on the billing transaction.

The Medicare Secondary Payer (MSP) Primary Payer amount when the primary insurance made payment on the billing transaction.

The dollar amount of charges that are not covered by Medicare.

The dollar amount of interest paid by Medicare. Interest is paid on clean billing transactions that are not paid within the 30-day timeframe.

For home health outpatient services (type of bill 34x), this is the total reimbursement amount for all covered services under the Medicare Physician Fee Schedule (MPFS).
Not applicable to hospice billing transactions.

The status of the billing transaction when it completed processing. The following codes are used by Medicare.

1

Paid as primary

2

Paid as secondary

3

Paid as tertiary

4

Denied (this claim status shows when a claim is denied or rejected).

19

Medicare paid primary and the Medicare Administrative Contractor (MAC) sent the claim to another insurer.

20

Medicare paid secondary and the Medicare Administrative Contractor (MAC) sent the claim to another insurer.

21

Medicare paid tertiary and sent the claim to another insurer.

22

Adjustment to prior claim, reversal to previous payment (this claim status shows when a claim is cancelled (TOB XX8), including RAPs which have been auto-cancelled or cancelled by the provider.

23

Not a Medicare claim and the Medicare Administrative Contractor (MAC) sent claim to another insurer.

 

Number of home health days used and applied to the Medicare Cost Report (MCR). This field does not apply to home health requests for anticipated payment (RAP) and hospice billing transactions.

The number of covered home health or hospice days or visits.

The number of non-covered home health or hospice days or visits<

The dollar amount associated with the adjusted DRG code.
Not applicable to home health and hospice billing transactions.

The dollar amount applied to the beneficiary's deductible. Applicable to home health outpatient therapy billing transactions (34X type of bill).

The dollar amount of denied charges. When charges are denied for reasons other than Medical Review, refer the Claim Adjustment Reason Code (CARC) in the RC field and/or the Remittance Advice Remark Codes (RARC) in the REM field for more information.

Indicates a presumptive payment adjustment on a billing transaction.

The net reimbursement for each billing transaction.

Medicare Beneficiary Identifier

 

The 2 percent payment reduction on billing transactions with dates of service on or after April 1, 2013. The RC field on the remittance will include the Claim Adjustment Reason Codes (CARCs) 253 to explain the adjustment in payment.

 
 

Population Based Payments (PBP) – Applies when provider agrees to participate in the Next Generation Accountable Care Organizations (ACO) Model.

This field represents the amount associated with value code 'Q7' (ISLET Add-On Payment Amount).

Billing transactions are grouped by Fiscal Year. If multiple FYs are present on a single remittance advice, a FY subtotal displays after each group of billing transactions.

Billing transactions for Part A and Part B services will appear on separate pages of the remittance advice, with respective subtotals.



Summary Page

The Summary page includes information that encompasses all the claims included in the AC section.

As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the field to view more detailed information.

Medicare Administrative Contractor (MAC) and Provider Information
General information about CGS, your Medicare Administrative Contractor (MAC) who processed the claims and distributed the SPR. This information appears on the top of every page. General information about the Medicare provider follows, which includes the provider's National Provider Identifier (NPI), name, and address.

The CLAIM DATA section of the summary page displays totals for all the billing transactions references on this SPR.

This section of the summary page contains Pass through amounts. These fields do not apply to home health and hospice billing transactions.

 
 

Not functional.

This section of the summary page displays all provider payments made on this SPR and can be used for transaction-level balancing. To obtain the total payment amount (NET PROVIDER PAYMENT), add all the amounts in the PAYMENTS section. Then subtract the amount shown in the TOTAL WITHHOLD field, which is a negative amount representing the total of all provider adjustments.

Heading for the COST, COVDY and NCOVDY information.

Not functional

 

Summary of the total number of days applied to the Medicare Cost Report (MCR) for billing transactions processed on this SPR. Not applicable to home health and hospice billing transactions.

An additional payment made to a hospital for services provided by an intern or resident physician. Not applicable to home health and hospice billing transactions.

Heading for the payment recap section of the summary page.

Summary of covered home health or hospice days or visits for billing transactions processed on this SPR.

An additional payment amount made to a certified hospital for a kidney acquisition. Not applicable to home health and hospice billing transactions.

The total DRG outlier amount for billing transactions processed on this SPR. Not applicable to home health and hospice billing transactions.

Summary of non-covered home health or hospice days for billing transactions processed on this SPR.

The dollar amount of reimbursable bad debts. These debts include coinsurance and deductibles that a hospital is unable to collect from a beneficiary. Not applicable to home health and hospice billing transactions.

The total amount of interest paid by Medicare for billing transactions processed on this SPR.  Interest is paid on clean billing transactions if Medicare payment is not made within 30 calendar days. Reference: Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, Section 80.2.2

 

The reimbursement amount a hospital receives for Certified Registered Nurse Anesthetist (CRNA) services. Not applicable to home health and hospice billing transactions.

The total procedure code payable amounts for billing transactions processed on this SPR. Not applicable to home health and hospice billing transactions.

Heading for the COVD, NCOVD and DENIED information.

A total of the pass thru amounts in the Pass Thru Amounts section of the SPR. Not applicable to home health and hospice billing transactions.

The total net reimbursement amount made to the provider for billing transactions processed on this SPR.

Summary of covered charges for billing transactions processed on this SPR.

 

A total of the pass thru amounts in the Pass Thru Amounts section of the SPR. Not applicable to home health and hospice billing transactions.

Summary of non-covered charges for billing transactions processed on this SPR.

The dollar amount of the Periodic Interim Payment (PIP) paid to the provider. Not applicable to home health billing transactions.

The dollar amount of the Periodic Interim Payment (PIP) paid to the provider. Not applicable to home health billing transactions.

Summary of denied charges for billing transactions processed on this SPR.

The refund amount issued for settlement payments.

The refund amount issued for settlement payments.

   

The dollar amount of an accelerated payment made to a provider.

 

Indicates refunds unrelated to settlement payments.

Indicates refunds unrelated to settlement payments.

Summary of the professional component amount for billing transactions processed on this SPR.

The dollar amount of money being released previously withheld from a provider on penalty withhold.

The dollar amount of money being released previously withheld from a provider on penalty withhold.

Summary of MSP payment made for billing transactions processed on this SPR.

The amount of a Transitional Outpatient Payment. Not applicable to home health and hospice billing transactions.

The total TOP amount paid on this SPR. Not applicable to home health and hospice billing transactions.

Summary of deductible payments owed to the provider by beneficiaries for billing transactions processed on this SPR.
Applicable to home health outpatient therapy billing transactions (34X type of bill).

An additional payment amount an inpatient hospital receives for the hemophilia blood-clotting factor. Not applicable to home health and hospice billing transactions.

The total hemophilia add-on amount paid on this SPR. Not applicable to home health and hospice billing transactions.

Summary of the coinsurance amount owed to the provider by beneficiaries for billing transactions processed on this SPR.
Applicable to home health outpatient therapy billing transactions (34X type of bill).

An additional dollar amount Medicare paid for 'new technology' drugs and devices. Not applicable to home health and hospice billing transactions.

The total dollar amount of funds Medicare paid for 'new technology' drugs and devices on this SPR. Not applicable to home health and hospice billing transactions.

 

This field represents the amount associated with value code 'Q7' (ISLET Add-On Payment Amount).

This field represents the amount associated with value code 'Q7' (ISLET Add-On Payment Amount).

 

The amount of a check/payment that has been voided and reissued. Not applicable to home health and hospice billing transactions.

The total amount of a check/payment that has been voided and reissued on this SPR.

 

Not applicable for home health and hospice services

Not applicable for home health and hospice services

   

The outstanding balance owed to Medicare that is carried forward to the next SPR. For additional information, refer to the "Remittance Advice (RA)/Electronic Remittance Advice (ERA) Payment Summary Page and Forward Balances (FB)" article on the CGS website.

Summary of the beneficiary refund amount for billing transactions processed on this SPR.

This section of the summary page includes the amount(s) withheld from payments.

The total amount withheld for billing transactions processed on this SPR. This amount is the sum from the WITHHOLD FROM PAYMENTS section of the SPR.

Summary of the interest paid to the provider for clean billing transactions that were not processed within the 30-day timeframe.

The amount withheld from the current SPR's net reimbursement and applied to an existing claim receivable balance. The claim receivable balance would have been created and carried forward from a net negative reimbursement on a previous SPR. A net negative reimbursement is usually caused by a cancellation or adjustment to a previous paid billing transaction. When the net negative reimbursement exceeds total payments, a claim receivable balance carries forward and offsets future payments. CGS recommends that you monitor negative net reimbursement totals on SPRs in order to identify the claim receivable withholdings that are recouped on future SPRs.

This amount displays when forced balancing of the SPR is required.

Summary of the contractual adjustment amount for billing transactions processed on this SPR.

The dollar amount being withheld to recover an accelerated payment previously paid to the provider.

The net amount being paid to the provider. This amount should match the check amount issued to the provider.

Summary of the procedure code payable amount for billing transactions processed on this SPR.
Not applicable to home health and hospice billing transactions.

The payment amount withheld from a provider due to an unfiled Medicare Cost Report, a payment suspension or a credit balance report not being submitted in a timely manner.

The total dollar amount that a provider receives for billing transactions included on this remittance advice.

The dollar amount withheld from a provider due to an unpaid settlement owed to Medicare.

The check or Electronic Funds Transfer (EFT) transaction number through which payment was issued.

 

The dollar amount withheld from a provider due to a third party payment.

 
 

The payment amount withheld from an affiliated provider.

 
 

The payment amount withheld from a provider due to a recoupment owed to Medicare.

 
 

The payment amount withheld from a provider due to overdue taxes owed to the Internal Revenue Service (IRS).

 
 

The payment amount withheld from a provider due to unpaid debts. Typically, these withholdings are Treasury requested offsets for unpaid Medicare or VA overpayments of the provider or an affiliated providers.

 
 

A total of the withholding amounts in the Withhold From Payments section of the SPR.

 

Updated: 11.16.20

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