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Interactive Medicare Part B Remittance Advice (RA) Tool

The Medicare Standard Provider Remittance (SPR), also referred to as a Remittance Advice (RA), is a notice sent to Part B providers explaining how billing transactions are processed (paid, rejected, or denied). Billing transactions include final claims, adjustments, and canceled, denied, or rejected claims. RAs in a hardcopy SPR format are not provided if the Part B provider has received the Electronic Remittance Advice (ERA) for more than 45 days.

This interactive guide provides an overview of the RA. Select the section (below) that you wish to view. As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the field to view more detailed information.

The RA includes four basic sections:

  • Header Information – This section contains header information specific to the provider and a bulletin board section for information important to the provider.
  • Assigned Claims – This section contains detailed information on each claim submitted on an assigned basis.
  • Unassigned Claims – This section contains detailed information on each claim submitted on an unassigned basis. It is identified with the heading "SUMMARY OF UNASSIGNED CLAIMS," and appears on a separate page of the RA.
  • Glossary – This section identifies and defines the CARCs and RARCs for each service on the RA.

Header Information

The Header Information section contains indentifying information for the MAC and the provider. There is also a bulletin board area that is used by the MAC to share news and information related to Medicare.

As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the fieldto view more detailed information. (Text for each field is noted in the right margin and the chart below)

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Assigned Claims

The Assigned Claims section starts with a header row, identifying the information in each of the columns in the Assigned Claims section. After the header row, information on each claim filed with an "assigned" status is listed. Claims are listed in alphabetical order by patient's last name. Claim-level and service-line-level information for the claim is listed.

As you move your mouse over the area of interest, the field(s) will highlight and the name of the field will display. Click on the field to view more detailed information. (Text for each field is noted in the chart below)

The National Provider Identifier (NPI) of the provider who performed the service. The to/from date the service was rendered. The code that represents the place of service. The number of services/units billed on the service. The CPT/HCPCS code submitted for the service. The modifier submitted with the CPT/HCPCS code (if applicable). The billed amount for the service. The amount we allowed for the service. The amount applied to the patient's deductible. The amount the patient is responsible for paying (20% of the allowed amount). The Group/Reason Code Amount represents the financially responsible party and explain denials and payments. The amount we paid the provider for the service.
The last name and first name of the patient for whom the claim was submitted and processed. The patient's Health Insurance Claim (HIC) number. This is the account number assigned by the provider. If submitted on the claim, it will appear in this field to help with identifying the patient. The Internal Control Number (ICN) is a 13-digit number assigned by the claims processing system. It is unique to the claim for which it was assigned. This field shows the assignment of the claim. A 'Y' means assignment was accepted; an 'N' means assignment was not accepted. Medicare Outpatient Adjudication (MOA) field contains Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs) at the claim level. Refer to http://www.wpc-edi.com/codes for a complete listing. This is the National Provider Identifier (NPI) of the performing provider.
This is the from/to date the service was rendered. This is the two-digit place of service code. Displays the number of services (units) submitted on the claim. This is the CPT or HCPCS code submitted on the claim. The modifiers submitted with the CPT/HCPCS code. Up to four modifiers may be shown. The amount the provider billed for the service. This is the amount CGS allowed on the service. Money applied to the patient's unmet annual deductible will appear here. Money applied here is the coinsurance amount billed to the patient or other insurer. Group Codes and Claim Adjustment Reason Codes (CARCs) are listed here. Refer to the Glossarysection for definitions. Refer to http://www.wpc-edi.com/codes for a complete listing of CARCs. The amount of the adjustment associated with the Group Code and CARC. The amount the provider was paid for the service.
This is the Remark Code associated with the service line. Refer to http://www.wpc-edi.com/codes for a complete listing of Remark Codes.
The total amount the patient or other insurer is responsible for paying the provider. This is the total amount billed on the claim for all line items. The total amount CGS allowed for the entire claim. This is the total amount applied towards the patient's deductible for the entire claim. The total amount of the patient's coinsurance for the entire claim. This is the total amount of adjustment made on the claim. The amount paid to the provider for the entire claim.
This is displayed when a claim is forwarded to a patient's supplemental insurer. The net amount the provider is being paid.
This is the total number of claims on the RA. The total amount billed for all claims on the RA. This is the total allowed for all claims on the RA. The total amount applied to the patient's unmet deductible for all claims on the RA. This is the total coinsurance for all claims on the RA. This is the total amount of adjustments made on the entire claim. The amount the provider is paid for all claims on the RA. This is the total amount of any provider-level adjustments made on the RA. The check amount. This amount is the total of claim payment amounts minus the total provider-level adjustments.
This is the provider-level adjustment reason code used to define the reason the claim was adjusted. This number is associated with an offset. For information regarding the offset, refer to the Interactive Voice Response (IVR) System. The IVR User Guide is availale at /partb/cs/partb_ivr_user_guide.pdf. This is the amount of the adjustment associated with the Financial Control Number (FCN). This is the patient associated with the Financial Control Number (FCN).

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Glossary

The Glossary section contains a listing of all Group Codes, RARCs, CARCs, and Provider-Level Adjustment Reason Codes that appear on the RA. Refer to this section for an explanation of the decisions CGS made on your claims. All of the RARCs and CARCs are available to you at http://www.wpc-edi.com/codes.

GLOSSARY: Group, Reason, MOA, Remark and Adjustment Codes
CO Contractual Obligation. Amount for which the provider is financially liable. The patient may not be billed for this amount.
PR Patient Responsility. Amount that may be billed to a patient or another payer.
119 Benefit maximum for this time period or occurrence has been reached.
223 Adjustment code for mandated federal, state or local law/regulation that is ot already covered by another code and in mandated before a new code can be created.
246 This non-payable code is for required reporting only.
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
59 Processed based on multipl or concurrent procedure rules.
MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. In order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless youhave a good reason for being late.
MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.
N365 This procedure code is not payable. It is for reporting/information purposes only.
WO Overpayment Recovery

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The following resources are available on the Centers for Medicare & Medicare Services (CMS) website.

Providers who have registered for myCGS (the CGS Web portal) are able to view and print standard paper remittances.

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