Remittance Advice Guidelines (Palmetto GBA Providers)
Remittance Advice is sent to nonparticipating physicians, suppliers, and non-physician practitioners billing non-assigned claims, unless the beneficiary or the provider requests that the remittance advice be suppressed. An informational Remittance Advice is identical to other RAs, but must carry a standard message to notify providers that they do not have appeal rights beyond those afforded when limitation on liability. Information on nonassigned claims will be listed separately after the assigned claims. In addition to the provider Remittance Advice, Medicare beneficiaries also receive Medicare Summary Notice (MSN). The Remittance Advice contains message codes which explain how a claim was processed. There are three different sets of codes that are used on the RA.
Reason codes are used to explain why a claim was not paid or how the claim was paid. They also show the reason for any claim financial adjustments, such as denials, reductions or increases in payment. Under the standard format, only reason codes approved by the ANSI X12.835 Insurance Subcommittee and Medicare specific supplemental messages approved by CMS may be used.
Medicare Specific Remark Codes and Messages
The X12.835 reason codes were created as generic messages to be used by all national health payers. Therefore, they are not specific to Medicare. CMS created appeals and developmental codes and messages specific to Medicare. CMS remark codes are informational messages that cannot be expressed with an ANSI reason code. These codes are service-specific.
Group codes will be used to indicate when a beneficiary may or may not be billed for the unpaid balance of the services that were performed. These codes correspond with information that is already being furnished to beneficiaries via MSNs. The group codes and their explanations follow:
PR (Patient Responsibility)
This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf.
CO (Contractual Obligation)
This includes any amounts for which the provider is financially liable. The patient may not be billed for these amounts.
OA (Other Adjustment)
This is used if neither PR or CO is applied.
Explanation of Codes and Messages
The Remittance Advice will always provide the text of each reason and message code at the end of the notice.