LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

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.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

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.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  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.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

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Remittance Advice Instructions Tool

Hover over the image of Standard Paper Remittance Advice (SPR) to view information and descriptions. Many of the descriptions will also apply to the Electronic Remittance Advice (ERA), though they may not appear in the same order.

Medicare carrier/ MAC identification, complete address, and Customer Service Number

Document Title

Provider's name and billing address

Provider's National Provider Identifier (NPI), Number of pages included in the Remittance Advice, The Remittance Advice Date, the Check date, the Check/EFT number and the statement number of the Medicare Remittance Advice

The performing provider obtained from either Item 24J (if a provider within a group) or 33 (if a sole provider) on the CMS-1500 Claim Form.

SERV DATE = The Dates of Service as entered in field 24A on the CMS-1500 Claim Form

The Place of Service from field 24B on the CMS 1500 Claim Form.

Number of services from field 24G on the CMS 1500 Claim Form.

The HCPCS procedure code from item 24D on the CMS-1500 Claim Form. If a procedure code is changed while a claim is being processed, the paid code will be listed in this field followed by a CC (Code Change) modifier. The originally submitted procedure code will appear in parentheses under the paid procedure code.

The HCPCS modifiers are printed in the MODS column. Up to four modifiers are printed. Modifiers printed will be those reported in item 24D of the CMS-1500 Claim Form or any modifier added by CGS for pricing reduction or notification of a change to the submitted procedure code.

The amount billed for each service. This amount is the amount that was submitted on the CMS-1500 Claim Form item 24F.

The Medicare reimbursement rate for the specific service billed.

The deductible amount, if any, that was applied to the claim. The beneficiary, or other insurer, is responsible for paying this amount to the provider.

Note: Check Beneficiary Eligibility in the myCGS Web Portal for the beneficiary's remaining deductible amounts.

The amount for a service for which the beneficiary is responsible. If there is an amount displayed in this field, the beneficiary (or other insurer) is responsible for paying this to the provider. Coinsurance amounts are subject to change annually.

GRP/RC-AMT = Group Codes/Reason Codes - Amount. Any adjustment amounts and reason codes are printed under this column. Group (GRP) values are:

  1. PR - Patient Responsibility
  2. CO - Contractual Obligation
  3. OA - Other Adjustment
  4. CR - Correction to, or reversal of, a prior decision

PROV PD - The amount that is paid to the provider for the specific line item it is associated with is printed in this column. The PROV PD amount does not include any amounts in the PREV PD, INT, or LATE FILING CHARGE Fields in the Provider Adjustments Details Section.

The name of the beneficiary as printed on the CMS-1500 Claim Form item 2.

The beneficiary's Medicare ID number or Medicare Beneficiary Identifier as printed on the CMS-1500 Claim Form item 1a. If a Medicare ID number is a HICN, the first 5 numbers will be masked.

The beneficiary's account number used within the supplier's office if it has been provided in item 26 of the CMS-1500 Claim Form. If no internal number was submitted on the claim, this field will display a zero. If this field contains a HICN or SSN, this field will be masked.

The 13 digit Internal Control Number. This number identifies the claim within the DME MAC's processing system. You will need this number if you need to contact CGS about the claim. At times, the ICN is also referred to as the CCN, which is the Claim Control Number. The two terms describe the same number and are used interchangeably.

This field indicates whether or not the provider accepted assignment. This information is pulled from Item 27 on the CMS-1500 Claim Form.

Medicare Outpatient Adjudication (MOA) remark codes indicate information that is not part of a financial adjustment. This field will contain a maximum of 5 MOA remarks codes per ICN. Definitions for the listed codes will be in the glossary at the end of the remittance advice.

PERF PROV = The performing provider information obtained from either Item 24J (if a provider within a group) or 33 (if a sole provider) on the CMS-1500 Claim Form

SERV DATE = The Dates of Service as entered in field 24A on the CMS-1500 Claim Form

The Place of Service from field 24B on the CMS 1500 Claim Form.

Number of services from field 24G on the CMS 1500 Claim Form.

The HCPCS procedure code from item 24D on the CMS-1500 Claim Form. If a procedure code is changed while a claim is being processed, the paid code will be listed in this field followed by a CC (Code Change) modifier. The originally submitted procedure code will appear in parentheses under the paid procedure code.

The HCPCS modifiers are printed in the MODS column. Up to four modifiers are printed. Modifiers printed will be those reported in item 24D of the CMS-1500 Claim Form or any modifier added by CGS for pricing reduction or notification of a change to the submitted procedure code.

The amount billed for each service. This amount is the amount that was submitted on the CMS-1500 Claim Form item 24F.

The Medicare reimbursement rate for the specific service billed.

The deductible amount, if any, that was applied to the claim. The beneficiary, or other insurer, is responsible for paying this amount to the provider.

Note: Check Beneficiary Eligibility in the myCGS Web Portal for the beneficiary's remaining deductible amounts.

The amount for a service for which the beneficiary is responsible. If there is an amount displayed in this field, the beneficiary (or other insurer) is responsible for paying this to the provider. Coinsurance amounts are subject to change annually.

The amount for a service for which the beneficiary is responsible. If there is an amount displayed in this field, the beneficiary (or other insurer) is responsible for paying this to the provider. Coinsurance amounts are subject to change annually.

PROV PD - The amount that is paid to the provider for the specific line item it is associated with is printed in this column. The PROV PD amount does not include any amounts in the PREV PD, INT, or LATE FILING CHARGE Fields in the Provider Adjustments Details Section.

Patient Responsibility. This field shows the full amount for which the beneficiary, or their other insurer, may be held liable for payment by the provider. All denials or reductions from the provider's billed amount with a group code of PR, including the deductible and co-insurance, are totaled in this field at the end of each claim.

CLAIM TOTAL – This line will show totals for the individual claim. It includes totals for the columns BILLED, ALLOWED, DEDUCT, COINS, GRP/RC-AMT, and PROV PD.

When viewing the total for the GRP/RC-AMT column, note that any amounts that have a group code of CR, or are listed as a previously paid amount, will be excluded from this total.

This line will show any adjustments that have been made to the total amounts paid on the claim.

Amounts that were paid on the original claim if the claim has been adjusted.

The amount of interest paid on the original claim. The amount displayed is the difference between the current interest on the adjustment claim and the previous interest from the original claim.

This field will show the total of late filing charges from each line of the claim. The amount will be negative if the previous late filing charge is more than the current late filing charge. The amount will be positive if the previous late filing charge is less than the current late charge.

The net paid amount for the claim, including the interest.

Totals for the Assigned Claims section of the Standard Paper Remittance.

The total number of assigned claims included on the remittance advice.

The total amount billed for the assigned claims included on the remittance advice.

The total allowed for the assigned claims included on the remittance advice.

The total amount of the deductibles of all of the assigned claims included on the remittance advice.

The total amount of the coinsurance for all of the assigned claims reported on the remittance advice.

The total amount of the adjustments made to the assigned claims included on the remittance advice due to claim adjustment reason codes (CARCs) listed on the individual service lines. This amount excludes interest, late filing charges, deductibles, and previously paid amounts.

The total amount of the payment for assigned claims prior to application of provider adjustments.

The total amount of the provider adjustment details section for the assigned claims on the remittance advice.

The system calculated check amount. This field will display an amount of $0 on duplicate provider remittance advices even when the original showed a payment amount.

This section will display any offsets to payments. These offsets are shown in this section rather than as an adjustment at an individual claim level.

If there are any unassigned claims included on the Standard Paper Remittance, they will appear in a separate section beneath the Assigned claims and before the Provider Adjustment Details section. The headings and descriptions for the fields will be the same as for assigned claims. However, the ASG field will show an "N" instead of a "Y".

The reason code for payment offsets is shown in this field. The explanation for the reason code will be in the Glossary section of the Remittance Advice.

Financial control numbers. FCNs are provided so that providers are able to associate the offset with the claims and payments that led to the withholding.

Claim Control Number- the CCN of the claim the adjustment is associated with. If there is more than one, this field will be left blank. At times, the CCN is also referred to as the ICN, which is the Individualized Control Number. The two terms describe the same number and are used interchangeably.

If the offset is for a Medicare overpayment, and a Medicare ID is associated with the offset, then the Medicare ID will be printed in this field. If there is more than one associated Medicare ID, they will not be printed here.

The amount that is being added by, or withheld by, the FCN transaction is always printed at the provider summary level.

Codes that appear in the remittance advice will be described in the glossary. The codes will be listed in the following order:

  1. Group codes
  2. Reason codes
  3. Line level remark codes
  4. Claim level remark codes/ MOA
  5. Claim and detail level remark codes
  6. Adjustment codes

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