Get documents about "PROFESSIONAL RA
Document Sample
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX1
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD DD MM DD YY UNITS CHARGES
TO ALL PROVIDERS
THE PURPOSE OF THE “RA MESSAGE”
IS TO KEEP YOU INFORMED.
PLEASE READ EACH ONE AND
CONTACT EDS IF YOU HAVE ANY
QUESTIONS CONCERNING THE RA
MESSAGE.
PROVIDER NAME REMITTANCE ADVICES CANNOT BE FORWARDED.
100 MAIN ST THEREFORE, THE ARKANSAS MEDICAID PROGRAM
ANYWHERE, AR 12345 MUST BE NOTIFIED OF AN ADDRESS CHANGE WITH
THE PROVIDER’S ORIGINAL SIGNATURE (NO
FACSIMILE). PLEASE INDICATE ALL PROVIDER
NUMBERS AFFECTED BY THE CHANGE.
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX2
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
PAID CLAIMS
MEDICAL
DOONE, ASHLEY P CO = 60 RCC = XXXX CLAIM NUMBER = 0503175123456 MRN = 22224098086XXXXXXXXX DIAG = 34690XX SERV PHYS = 123456178
0123456777 05 16 03 05 20 03 XX122 Q NNNNN 00 BILLING DESCRIPTION 500 00 10 00 490 00 00 00 00 490 00 61
RCRC REVENUE CODE DESCRIPTION
MODIFIERS = XX XX XX XX
COST SHARE = XXXXXXX.00 PA NUMBER = 2305040241 TPL = XXXXXXX.00 500 00 10 00 490 00 00 00 00 490 00 TAX = 00
LEA = XXXXX XXXXX XXXXX XXXXX
1 CLAIMS 1 MEDICAL **************** 500 00 10 00 490 00 00 00 00 490 00
TAX=00
May 2007 Professional Remittance Advice Example - 1
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX3
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
PAID CLAIMS
PROFESSIONAL CROSSOVER
BLACK, JOHN A CO = 60 RCC = XXXX CLAIM NUMBER = 0503178123456 MRN = 48224098086XXXXXXXXX DIAG = 34690XX SERV PHYS = 123456178
0123456777 05 20 03 05 20 03 XX120 Q NNNNN 00 220 00 00 220 00 00 00 00 220 00 33
COST SHARE = XXXXXXX.00 MCR = XXXXXXXXXXXXXXXX
COINS = XXXXX20.00 DED = XXXXX20.00 MCR PD = 80.00 TPL = 00 220 00 00 220 00 00 00 00 220 00 TAX = 00
1 CLAIMS 1 PROFESSIONAL CROSSOVER **************** 220 00 00 220 00 00 00 00 220 00
TAX=00
******** TOTAL PAID CLAIMS 2 CLAIMS 720 00 10 00 710 00 00 00 00 710 00
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX4
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
ADJUSTED CLAIMS
PROFESSIONAL ADJUSTMENT
BRADLEY, HOPE T CO = 41 CLAIM NUMBER = 5003145970456 ** ADJUSTMENT ** CREDIT TO 0502292125456 PAID DATE 102802
0112233456 04 16 03 04 16 03 MED REC = 6778087453XXXXXXXXXX 35 00 35 00
BRADLEY, HOPE T CO = 41 CLAIM NUMBER = 5003145970456 ** ADJUSTMENT ** DEBIT TO 0502292125456 PAID DATE 102802 SERV PHYS = 123456178
0112233456 04 16 03 04 16 03 XX122 Q NNNNN 00 BILLING DESCRIPTION 35 00 5 00 30 00 00 00 30 00 162
RCRC REVENUE CODE DESCRIPTION
MODIFIERS = XX XX XX XX
ADJUSTMENT OF CLAIM 0502292125456 NET ADJUSTMENT XXXXXX5.00CR TAX=00
COST SHARE = 00 PA NUMBER = XXXXXXXXXX TPL = 00 MED REC = 6778087453XXXXXXXXXX
1 CLAIMS 1 PROFESSIONAL ADJUSTMENT ***** 35 00 5 00 30 00 00 00 30 00
******** TOTAL ADJUSTED CLAIMS 1 CLAIMS
TOTAL NET ADJUSTMENT XXXXXX5.00CR TAX=00
May 2007 Professional Remittance Advice Example - 2
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX5
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
DENIED CLAIMS
MEDICAL
RED, JAKE R CLAIM NUMBER = 0503160654321 MRN = 9384756XXXXXXXXXXXXX DIAG = 2449XXX SERV PHYS = 123456178
1234567010 05 02 03 05 05 03 XXX10 NNNNN 00 BILLING DESCRIPTION 100 00 470
RCRC REVENUE CODE DESCRIPTION
MODIFIERS = XX XX XX XX
PA NUMBER = XXXXXXXXXX TPL = XXXXXXX.00
1 CLAIMS 1 MEDICAL **************** 100 00 100 00 00 00 00 00 00
TAX=00
******** TOTAL DENIED CLAIMS 1 CLAIMS 100 00 100 00 00 00 00 00 00
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX6
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
CLAIMS IN PROCESS — THESE CLAIMS ARE BEING PROCESSED AS LISTED
PROFESSIONAL
BRADLEY, HOPE T
3214567005 05 02 03 05 02 03 ICN = 0503155456123 201 00 MRN = 7364582XXXXXXXXXXXXX 14
GOODSON, SAM M
1234657001 05 10 03 05 10 03 ICN = 0503164456231 301 00 MRN = 0946522XXXXXXXXXXXXX 14
BLAKE, JESSICA T
1234567001 05 12 03 05 12 03 ICN = 0503167456321 401 00 MRN = 1635722XXXXXXXXXXXXX 14
TALLEY, JANE R
1234567010 05 22 03 05 22 03 ICN = 0503175456432 501 00 MRN = 2464758XXXXXXXXXXXXX 14
4 CLAIMS 4 INSTITUTIONAL OUTPATIENT ***** 1404 00
******** TOTAL PENDING CLAIMS 4 CLAIMS 1404 00
May 2007 Professional Remittance Advice Example - 3
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX7
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
FINANCIAL ITEMS
RECIP ID FROM TXN CONTROL REFERENCE ORIGINAL BEGINNING APPLIED NEW HEOB
DOS DATES NUMBER AMOUNT BALANCE AMOUNT BALANCE
0123456777 02 03 03 05 21 03 3060701710 5103177982779XXXXXXX1179508261XXXXXXXXXX 120 00 120 00 120 00 00 112
0123456999 03 07 03 05 21 03 3060705075 5103177982784XXXXXXX1179508571XXXXXXXXXX 60 00 60 00 60 00 00 112
0123456888 04 10 03 05 21 03 3060705188 5103177982775XXXXXXX1179508925XXXXXXXXXX 54 00 54 00 54 00 00 112
0123456987 XX XX XX 05 21 03 3060705400 DEFERRED COMP WITHHOLDINGXXXXXXXXXXXXXXX 234 00 234 00 234 00 00 112
TOTAL FINANCIAL ITEMS 4 *******
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX8
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD YY MM DD YY UNITS CHARGES
AEVCS TRANSACTIONS
TRANSACTION CATEGORY TRANSACTION COUNT TRANSACTION AMOUNT
CLAIM EPSDT 24 4 08
HCFA 01 17
TOTAL CLAIM TRASACTIONS 25 4 25
REVERSAL TOTAL REVERSAL TRASACTIONS 0
CLAIM STATUS LOOKUP TOTAL LOOKUP TRASACTIONS 0
ELIGIBILITY VERIFICATION 35 3 50
TOTAL TRANSACTIONS FOR THIS PROVIDER 60 7 75
May 2007 Professional Remittance Advice Example - 4
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXXX9
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD DD MM DD YY UNITS CHARGES
CLAIMS PAYMENT SUMMARY
DAYS OR CLAIMS CLAIMS WITHHELD NET PAY CREDIT NET 1099
UNITS PAID AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT
CURRENT PROCESSED XX374 XXXXXXX4 XXXX740.00 234 00 508 25 00 516 00
YEAR-TO-DATE TOTAL X2244 XXXXXX24 XXX4440.00 1404 00 3049 50 00 3096 00
AEVCS AEVCS TXN DEF COMP
TXN FEES RECOUP AMT RECOUP AMT *************************************
CURRENT PROCESSED 7.75 7.75 .00 PROVIDER PAID VIA EFT
*************************************
YEAR-TO-DATE TOTAL 46.50 46.50 .00
ARKIDS 1ST/CHIP/MEDICAID SUMMARY
ARKIDS 1ST CHIP MEDICAID
CLAIMS TOTAL PAID CLAIMS TOTAL PAID CLAIMS TOTAL PAID
DRUG 0 0.00 0 0.00 0 0.00
DRUG ADJUSTMENT 0 0.00 0 0.00 0 0.00
MEDICAL 0 0.00 0 0.00 1 490.00
DENTAL 0 0.00 0 0.00 0 0.00
SCREEN 0 0.00 0 0.00 0 0.00
PROFESSIONAL CROSSOVER 0 0.00 0 0.00 0 0.00
VISION 0 0.00 0 0.00 0 0.00
PROFESSIONAL ADJUSTMENT 0 0.00 0 0.00 0 0.00
INPATIENT HOSPITAL 0 0.00 0 0.00 0 0.00
INPATIENT NURSING HOME 0 0.00 0 0.00 0 0.00
INPATIENT CROSSOVER 0 0.00 0 0.00 0 0.00
NURSING HOME CROSSOVER 0 0.00 0 0.00 0 0.00
INPATIENT ADJUSTMENT 0 0.00 0 0.00 0 0.00
OUTPATIENT 0 0.00 0 0.00 0 0.00
OUTPATIENT CROSSOVER 0 0.00 0 0.00 0 0.00
OUTPATIENT ADJUSTMENT 0 0.00 0 0.00 0 0.00
May 2007 Professional Remittance Advice Example - 5
Professional Remittance Advice Example
MEDICAL ASSISTANCE LITTLE RIVER MEMORIAL HOSPITALXXX
100 ANYWHERE STREETXXXXXX
REMITTANCE AND STATUS REPORT XXXXXXXXXXXXXXXXXXXXXXXXX
ANYWHEREXXXXXXXX, AR 71822-XXXX
STATE OF ARKANSAS R/A NUMBER 1234567
NATIONAL PROVIDER IDENTIFIER (NPI) 1234567890
PROVIDER NUMBER 100200105 CNTRL NUM 12345 REPORT SEQ NUMBER XXXX9 DATE 06/13/03 PAGE XXX10
NAME SERVICE DATES DAYS PROCEDURE/REVENUE/DRUG TOTAL NON TOTAL SPENDDOWN PATIENT OTHER PAID HEOB CODES
RECIPIENT FROM TO OR CODE AND DESCRIPTION BILLED ALLOWED ALLOWED LIABILITY DEDUCTED AMOUNT
ID MM DD DD MM DD YY UNITS CHARGES
IF AN * APPEARS TO THE LEFT OF A DETAIL, A PAID DETAIL HAS BEEN ADDED SYSTEMATICALLY.
IF ** APPEARS TO THE LEFT OF A DETAIL, A DENIED DETAIL WAS ADDED SYSTEMATICALLY. RECOMMENDED BILLING INDICATED ON DETAIL. FEDERAL TAX ID SSN 431560654
THE FOLLOWING IS A DESCRIPTION OF THE HEOB CODES UTILIZED THROUGHOUT THE REPORT.
XXX14 CLAIM STILL IN PROCESS. PLEASE DO NOT REBILL.
XXX33 THIS PAYMENT, SUPPLEMENTED BY A PREVIOUS PAYMENT MADE BY MEDICARE, CONSTITUTES THE TOTAL PAYMENT. (NO RESPONSIBILITY ASSIGNED)
XXX61 PAID IN FULL BY MEDICAID. (NO RESPONSIBILITY ASSIGNED)
XX112 RECOUPMENT – THIS AMOUNT IS WITHHELD FROM YOUR CHECK. (NO RESPONSIBILITY ASSIGNED)
XX162 UNITS BILLED EXCEED MAC ALLOWED PER DAY. UNITS CUT BACK TO MAX ALLOWED FOR THE PROCEDURE. (NO RESPONSIBILITY ASSIGNED)
XX470 DUPLICATE OF CLAIM PAID. (PROVIDER RESPONSIBILITY)
May 2007 Professional Remittance Advice Example - 6
Related docs
Other docs by HC120915183526
