REMITTANCE ADVICES Print

The purpose of this section is to familiarize the provider with the design and content of the Remittance Advice (RA). This document plays an important communication role between the provider, the Bureau of Health Services Financing, and Gainwell Technologies. Aside from providing a record of transactions, the Remittance Advice will assist providers in resolving and correcting possible errors and reconciling paid claims.

THE PURPOSE OF THE REMITTANCE ADVICE

The RA is the control document which informs the provider of the current status of submitted claims. It is sent out weekly when the provider's claims have been adjudicated.

On the line immediately below each claim, a code is printed representing denial reasons, pended claim reasons, and payment reduction reasons. Messages explaining all codes found on the RA will be found on a separate page following the status listing of all claims. The only type of claim status which will not have a code is one which is paid as billed.

If the provider uses a medical record number (which may consist of up to 16 alpha and/or numeric characters), it will appear on the line immediately following the recipient's number.

At the end of each claim line is the 13-digit internal control number (ICN) assigned to that claim line. Each separate claim line is assigned a unique ICN for tracking and audit purposes. Listed below is a breakdown of the 13 digits of the ICN and what they represent:

Gainwell Technologies Provider Relations responds to inquiries concerning particular claims when the provider has reconciled the RA and determined that the claim has denied, pended, paid or been rejected prior to entry into the system. It is not possible for Gainwell Technologies Provider Relations to take the place of the provider's weekly RA by checking the status of numbers of claims on which providers, billers or collection agencies are checking.

In situations where providers choose to contract with outside billing or collection agencies to bill claims and reconcile accounts, it is the provider's responsibility to provide the contracted agency with copies of the RAs or other billing related information in order to bill the claims and reconcile the accounts. When providers or contractors are attempting to reconcile old accounts, if RAs are not available from the provider, it is necessary for the provider to order a claims history, which is available through Gainwell Technologies Provider Relations.

ELECTRONIC REMITTANCE ADVICES (ERAS)

>The EMC Department now offers Electronic Remittance Advices (ERAs). This allows  providers to have their Remittance Advices transmitted from Gainwell Technologies and posted to accounts electronically. There is a fee for this service. Further information may be obtained by calling the Gainwell Technologies EMC Coordinator at (225) 216-6239.

REMITTANCE ADVICE BREAKDOWN

Claims presented on the RA can appear under several headings: Approved Original Claims (paid claims); Denied Claims; Claims in Process; Adjustment Claims; Previously Paid Claims; and Voided Claims. When reviewing the RA, please look carefully at the heading under which the claims appear. This will assist with your reconciliation process.

Always remember that claims appear under the heading "Claims in Process" to let the provider know that the claim has been received by the Fiscal Intermediary, and should not be worked until they appear as either "Approved Original Claims" or "Denied Claims." "Claims in Process" are claims which are pending in the system for review. Once that review occurs, the claims will move to a paid or denied status on the RA. If claims pend for review, they will appear on an initial RA as "Claims in Process" as they enter the processing system. After that point, they will appear only once a month under that heading until they are reviewed.

REMITTANCE SUMMARY

"Approved Original Claims" may appear with zero (0 dollar) payments. These claims are still considered paid claims. Claims pay a zero amount legitimately, based on other insurance payments, maximum allowable payments, etc.

When providers choose to return checks to adjust or void a claim rather than completing an adjustment/void form, the checks will initially appear as a financial transaction on the front of the RA to acknowledge receipt of that check. The provider's check number and amount will be indicated, as well as an ICN which is assigned to the check. If claims associated with the check are processed immediately, they will appear on the same RA as the check financial transaction, under the heading of "adjustment or void" as appropriate, as well as the corresponding "previously paid claim." The amount of the check posted to the RA should offset the amount recouped from the RA as a result of the adjustment/void, and other payments should not be affected. However, if the adjustments/voids cannot be processed on the same RA, the check will be posted and appear on the financial page of the RA under "Suspense Balance Brought Forward" where it will be carried forward on forthcoming RAs until all adjustments/voids are processed. As the adjustments/voids are processed, they will appear on the RA and the amount of money being recouped will be deducted from the "Suspense Balance Brought Forward" until all claims payments returned are processed.

It is the provider's responsibility to track these refund checks and corresponding claims until they are all processed.

When providers choose to submit adjustment/void forms for refunds, the following is an important point to understand. As the claims are adjusted/voided on the RA, the monies recouped will appear on the RA appropriately as "Adjustment Claims" or "Voided Claims." A corresponding "Previously Paid Claim" will also be indicated. The system calculates the difference between what has already been paid ("Previously Paid Claim") and the additional amount being paid or the amount being recouped through the adjustment/void. If additional money is being paid, it will be added to your check and the payment should be posted to the appropriate recipient's account. If money is being recouped, it will be deducted from your check amount. This process means that when recoupments appear on the RA, the paid claims must be posted as payments to the appropriate recipient accounts through the bookkeeping process and the recoupments must be deducted from the accounts of the recipients for which adjustment or voids appear. If the total voided exceeds the total original payment, a negative balance occurs, and money will be recouped out of future checks. This also includes state recoupments, SURS recoupments and cost settlements.

Below are the summary headings, which may appear on the financial summary page and an explanation of each.

Denied claim turnarounds, also printed at the end of the remittance advice, are produced when certain errors are encountered in the processing of a claim. (Not all denial error codes produce denied claim turnarounds.) The denied claim turnaround document is printed to reflect the information submitted on the original claim. It is then mailed to the provider to allow him to change the incorrect items and sign and return the document to Gainwell Technologies. Once the document is received at Gainwell Technologies, the correction is entered into the claims processing system and adjudication resumes for the original claim. Note, however, that the turnaround document must be returned to Gainwell Technologies with appropriate corrections as soon as possible, as they are only valid for 30 days from the date of processing of the original claim.

The TPL denied claims notification list is generated when claims for recipients with other insurance coverage are filed to Medicaid with no EOB from the other insurance and no indication of a TPL carrier code on the claim form. This list notifies the provider that third party coverage exists and gives the name and carrier code of the other insurance. Once the private insurance has been billed, the claim may be corrected and resubmitted to Gainwell Technologies with the third party EOB.

REMITTANCE ADVICE COPY AND HISTORY REQUESTS

Provider participation in the Louisiana Medicaid Program is entirely voluntary. State regulations and policy establish certain requirements for providers who choose to participate in the program. One of those requirements is the agreement to maintain any information regarding payments claimed by the provider for furnishing services for a period of five years. It is the responsibility of the provider to retain all RAs for five years.

Effective November 1, 2011, Louisiana Medicaid stopped printing and mailing standard paper remittance advices to providers, billing agents, or other entities representing providers. Weekly standard paper remittance advices (RAs) are now posted on the secure side of the Louisiana Medicaid web site, www.lamedicaid.com, under the link, Weekly Remittance Advices. The documents are available in downloadable and printable PDF format. Providers who are not registered on the Louisiana Medicaid web site must register in order to access the website's secure portal. Once registered, providers may grant logon access to appropriate staff and/or any business partner entity representing them. Individuals who are allowed to access RAs will have the ability to download and save the documents or print the documents for reconciling accounts.

Providers must implement procedures for appropriate individuals to access this information online and to download and save or print RAs for internal use and future reference. Effective November 1, 2011, standard RAs are available only online through the web site. RAs will only be available online for five weeks.

When it is necessary for a provider to request copies of RAs dated prior to November 1, 2011 (the effective date of online RAs) or claim histories for payment dates prior to November 1, 2011, the FI will supply this information for a fee. If providers are requesting RAs prior to 11/01/11 for multiple weeks, the FI will determine whether RA copies or a claim history will be provided.

Requests for RAs or claims histories may be made through the Provider Relations Unit. The provider name, number, address, date(s) of the RA being requested, and name of the individual requesting and authorizing the request must be included in the request. Upon receipt of the request, the provider will be notified of the number of pages to be copied and the cost of the request. The RA/claims history will be forwarded to the provider once payment is received.

A fee of $0.25 per page, which includes postage, is charged to any provider who requests a copy of a Remittance Advice of one or more pages. Claims history fees may apply at the time of order.

NOTE: The transition to online Remittance Advices does NOT affect 835 electronic remittance advices received by many providers. Procedures and policies currently in place for HIPAA 835 electronic RAs remain the same.