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