HIPAA webinars

Oklahoma Health Care Authority HIPAA RA Guides

Providers receive a weekly remittance advice (RA) for any claims submitted the previous week. The RA identifies claims that are paid, denied, in process or adjusted. The RA includes the client ID number, the provider number, the Internal Control Number (ICN) of the claim processed, the date(s) of service and paid amount.

The RA also details any reductions to the paid amount, for reasons such as TPL and/or client copayment. Each claim detail might have an explanation of benefit (EOB) code explaining the reason for payment, denial, adjustment or inprocess statuses. RAs are tailored to individual claim form types—1500, UB-04, Dental and Pharmacy. When applicable, RAs include additional information, including procedure codes, revenue codes or admission and discharge dates for providers billing on the UB-04 claim form.

The RA is generated in each claim payment cycle. A provider will receive an RA if the provider has activity during the claim cycle or outstanding accounts receivable.

Remittance Advice Section Descriptions

The RA contains the following information:

  • Medicare Crossover – Paid Claims with a paid status are shown in this RA series, including claims paid at zero.
  • Medicare Crossover Denied – These claims have been denied payment.
  • Medicare Crossover in Process – Claims in the processing cycle not finalized are listed in this RA series. Claims found here include:
    • with attachments;
    • past the filing limit;
    • suspended;
    • requiring manual pricing; and
    • with adjustments that have not been finalized.
    • These claims have not been denied. Claims reflected as In Process are ultimately shown as paid, denied or adjusted on subsequent RAs. Claims in process must be monitored to final resolution.
  • Claims Paid – Claims with a paid status are shown in this RA series, including claims paid at zero.
  • Claims Denied – These claims have been denied payment.

Claims in Process

Claims in the processing cycle that have not been finalized are listed in this RA series. Claims found here include:

  • with attachments;
  • past the filing limit;
  • suspended;
  • requiring manual pricing; and
  • with adjustments that have not been finalized.

These claims have not been denied. Claims reflected as In Process are ultimately shown as paid, denied, or adjusted on subsequent RAs. Claims in process must be monitored to final resolution.

Each claim in process lists the EOB message that corresponds to the reason it has been suspended.

To learn more about EDI and become a certified EDI Professional, please visit our course schedule page.

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