SUBJECT: Remittance Advice Remark Code and Claim Adjustment Reason Code Update

Transcription

1 anual ystem Pub edicae laims Pocessing Depatment of ealth & uman evices (D) entes fo edicae & edicaid evices () Tansmittal 1031 Date: AUGUT 18, 2006 hange equest 5212 UBJET: emittance Advice emak ode and laim Adjustment eason ode Update. UAY O ANGE: This lists all changes in the emittance Advice emak ode and laim Adjustment eason ode lists included in the Apil 2006 and ebuay 2006 updates espectively. NEW / EVED ATEAL EETVE DATE: *Octobe 1, 2006 PLEENTATON DATE: Octobe 2, 2006 Disclaime fo manual changes only: The evision date and tansmittal numbe apply only to ed italicized mateial. Any othe mateial was peviously published and emains unchanged. oweve, if this evision contains a table of contents, you will eceive the new/evised infomation only, and not the entie table of contents.. ANGE N ANUAL NTUTON: (N/A if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Pe ow. /N/D hapte / ection / ubsection / Title N/A. UNDNG: No additional funding will be povided by ; contacto activities ae to be caied out within thei Y 2006 opeating budgets. V. ATTAENT: ecuing Update Notification *Unless othewise specified, the effective date is the date of sevice.

2 Attachment ecuing Update Notification Pub Tansmittal: 1031 Date: August 18, 2006 hange equest 5212 UBJET: emittance Advice emak ode and laim Adjustment eason ode Update. GENEAL NOATON A. Backgound: The ealth nsuance Potability and Accountability Act (PAA) of 1996 instucts health plans to be able to conduct standad electonic tansactions adopted unde PAA using valid standad codes. edicae policy states that laim Adjustment eason odes (As) ae equied in the emittance advice and coodination of benefits tansactions. edicae policy futhe states that emittance Advice emak odes (As) ae equied in the emittance advice tansaction. X12N 835 ealth ae emittance Advice emak odes is the national maintaine of the emittance advice emak code list. This code list is used by efeence in the A X12 N tansaction 835 (ealth ae laim Payment/Advice) vesion A1 mplementation Guide (G). Unde PAA, all payes, including edicae, have to use eason and emak codes appoved by X12 ecognized code set maintaines instead of popietay codes to explain any adjustment in the claim payment. As the ecognized maintaine of the A, eceives a significant numbe of equests fo new emak codes and modifications in existing emak codes fom edicae and non-edicae entities. Additions and modifications to the code list esulting fom non-edicae equests may not impact edicae. emak and eason code changes that impact edicae ae equested by staff in conjunction with a policy change. ontactos ae notified about these changes in the coesponding instuctions, which implement the policy change, in addition to the egula code update notification. f a modification has been initiated by an entity othe than fo a code cuently used by edicae, contactos shall use the modified code even though the modification was not initiated by edicae. f a new code is not initiated by edicae, contactos do not have to use it unless they have eceived specific instuction fom. ontactos shall stop using codes that have been deactivated on o befoe the effective date specified in the comment section (as posted on the WP Web site) if they ae cuently being used. edicae contactos shall not use any deactivated code past the deactivation date whethe the deactivation is equested by edicae o any othe entity. The complete list of emak codes is available at: The list is updated 3 times a yea. By Octobe 2, 2006 you must have completed enty of all applicable code text changes and new codes, and teminated use of deactivated codes. You must use the latest appoved and valid codes in you 835, coesponding standad pape emittance advice, and coodination of benefits tansactions. The following list summaizes changes made fom Novembe 1, 2005 to ebuay 28, 2006.

3 The A database has expanded apidly in the last couple of yeas. has developed a new Web site to help navigate the database moe easily. A tool is povided to help seach if you ae looking fo a specific categoy of code. You can also find at this site some othe infomation that ae available fom the WP Web site. The new Web site addess is: NOTE: This Web site is not eplacing the WP Web site as the official site whee the most cuent A list esides. f thee is any discepancy, always use the list posted at the WP Web site. emittance Advice emak ode changes New odes ode uent Naative edicae nitiated N365 This pocedue code is not payable. t is fo epoting/infomation puposes only. Y N366 N367 N368 N369 equested infomation not povided. The claim will be eopened if the infomation peviously equested is submitted within one yea afte the date of this denial notice. The claim infomation has been fowaded to a ealth avings Account pocesso fo eview. You must appeal the detemination of the peviously adjudicated claim. Alet: Although this claim has been pocessed, it is deficient accoding to state legislation/egulation. N N Y N odified odes ode uent odified Naative odification Date A02 f you do not agee with this detemination, you have the ight to appeal. You must file a witten equest fo an appeal within 180 days of the date you eceive this notice. Decisions made by a Quality mpovement Oganization (QO) must be appealed to that QO within 60 days. odified eff. 12/29/05 (*) This modification is effective Januay 1, 2006, and was implemented on o befoe ay 17, 2006.

4 Deactivated odes A03 f you do not agee with the appoved amounts and $100 o moe is in dispute (less deductible and coinsuance), you may ask fo a heaing within six months of the date of this notice. To meet the $100, you may combine amounts on othe claims that have been denied, including eopened appeals if you eceived a evised decision. You must appeal each claim on time. Deactivated effective 10/01/06, conside using emak code A02 X12 N 835 ealth ae laim Adjustment eason odes A national code maintenance committee maintains the health cae claim adjustment eason codes. The ommittee meets at the beginning of each X12 timeste meeting (ebuay, June and Octobe) and makes decisions about additions, modifications, and etiement of existing eason codes. The updated list is posted 3 times a yea afte each X12 timeste meeting. To access the list select elect laim Adjustment eason odes fom the pull down menu. All eason code changes appoved in ebuay 2006 ae listed hee. By Octobe 2, 2006, you must have completed enty of all applicable code text changes and new codes, and teminated use of deactivated codes. You must use the latest appoved and valid codes in you 835, coesponding standad pape emittance advice, and coodination of benefits tansactions. The equest fo a eason code change may come fom eithe edicae o non-edicae entities. f edicae equests a change, it may be included in a edicae instuction in addition to this egula code update notification. The egula code update notification is issued on a egula peiodic basis to povide a summay of changes in the eason and emak codes intoduced since the last update notification, and will establish the deadline fo edicae contactos to implement the eason and emak code changes that may not aleady have been implemented as pat of a pevious edicae policy change instuction. A eason code may be etied if it is no longe applicable o a simila code exists. etiements may be effective fo a specified futue and succeeding vesions o on a specific date. ontactos can discontinue use of etied codes in pio vesions. The egula code update notification will establish the deadline fo edicae contactos to etie a eason code. The edicae deadline could be ealie than the vesion o the date specified in the Washington Publishing ompany (WP) posting. The committee appoved the following eason code changes in ebuay eason ode hanges New odes ode uent Naative Notes 193 Oiginal payment decision is being maintained. This claim was pocessed popely the fist time. 194 Payment adjusted when anesthesia is pefomed by the opeating physician, the assistant sugeon o the attending physician. New as of 2/06 New as of 2/06

5 195 Payment denied/educed due to a efund issued to an eoneous pioity paye fo this claim/sevice New as of 2/06 odified odes None etied odes None B. Policy: o tansaction 835 (ealth ae laim Payment/Advice) and standad pape emittance advice, thee ae two code sets laim Adjustment eason ode (A) and emittance Advice emak ode (A) that must be used to epot payment adjustments, appeal ights, and elated infomation. Additionally, fo tansaction 837 OB, A must be used. These code sets ae updated on a egula basis. edicae contactos must use only cuently valid codes, and make the necessay changes on a egula basis as pe this ecuing code update o the specific that descibes the change in policy that esulted in the code change.. BUNE EQUEENT hall" denotes a mandatoy equiement "hould" denotes an optional equiement equiement Numbe equiements ntemediaies/s/aies/des and V shall update eason and emak codes that have been modified and apply to edicae by Octobe 2, esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W ntemediaies/s/aies/des and V shall update eason and emak codes to include new codes that apply to edicae by Octobe 2, ntemediaies/s/aies/des and V shall update eason and emak codes that have been deactivated whethe they apply to edicae o not by Octobe 2, 2006.

6 equiement Numbe equiements V shall update the edicae emit Easy Pint softwae to include the most cuent A and A lists available fom the following Web site: f you find any discepancy between any code text included in this and the coesponding text as posted on the Washington Publishing ompany (WP) Web site, use the text posted at the WP Web site. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V X W. POVDE EDUATON equiement Numbe equiements A povide education aticle elated to this instuction will be available at shotly afte the is eleased. You will eceive notification of the aticle elease via the established 'LN attes' listsev. ontactos shall post this aticle, o a diect link to this aticle, on thei Web site and include infomation about it in a listsev message within 1 week of the availability of the povide education aticle. n addition, the povide education aticle shall be included in you next egulaly scheduled bulletin and incopoated into any educational events on this topic. ontactos ae fee to supplement LN attes aticles with localized infomation that would benefit thei povide community in billing and administeing the edicae pogam coectly. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E X X X X V W

7 V. UPPOTNG NOATON AND POBLE DEGN ONDEATON A. Othe nstuctions: N/A X-ef equiement # nstuctions B. Design onsideations: N/A X-ef equiement # ecommendation fo edicae ystem equiements. ntefaces: N/A D. ontacto inancial epoting /Wokload mpact: N/A E. Dependencies: N/A. Testing onsideations: N/A V. EDULE, ONTAT, AND UNDNG Effective Date*: Octobe 1, 2006 mplementation Date: Octobe 2, 2006 Pe-mplementation ontact(s): umita en at umita.sen@cms.hhs.gov o No additional funding will be povided by ; contacto activities ae to be caied out within thei Y 2006 opeating budgets. Post-mplementation ontact(s): umita en at umita.sen@cms.hhs.gov o *Unless othewise specified, the effective date is the date of sevice.