Standard Paper Remittance (With Offset)

Because we receive a lot of questions regarding the Standard Paper Remittance, we decided to publish this interactive help page. By clicking on the links on the form, you can see an explanation of each field.

Novitas Solutions                                                                                   
2020 Technology Parkway                                                                                       
MECHANICSBURG PA 17055                                                                             
1-877-235-8073 
                                                                                            PROVIDER #:     120345
  PROVIDER NAME     		                                                                PAGE #:         1 0F 2
  ADDRESS LINE                                                                              DATE:         04/01/00
  CITY STATE ZIP                                                                            CHECK/EFT #:  88888888

        *********************************************************************************
                                      PROVIDER BULLETING MESSAGE
         In this section of the SPR you will find informational messages regarding the Medicare
         program.  This would include reminders, reference material and important information.
        *********************************************************************************

 PERF PROV SERV DATE  POS  NOS  PROC  MODS      BILLED  ALLOWED  DEDUCT   COINS  GRP/RC-AMT  PROV PD_________________________
NAME PEOPLES,JENNIE        HIC XXXXXXXXXA    ACNT            ICN XXXXXXXXXXXXX  ASG Y MOA MA01 MA18

631144ABC  0617061703 21   1   99291              613.00   193.94   0.00    38.79 CO-B6  419.06   155.15
631144ABC  0617061703 21   1   99291              613.00   193.94   0.00    38.79 CO-B6  419.06   155.15
631144ABC  0617061703 21   1   99291              613.00   193.94   0.00    38.79 CO-B6  419.06   155.15
PT RESP   116.37             CLAIM TOTALS        1839.00   581.82   0.00   116.37       1257.18   465.45
ADJS:  PREV PD  0.00  INT    1.11       LATE FILING CHARGE 0.00

__________________________________________________________________________________________________________________

TOTALS   # OF    BILLED     ALLOWED      DEDUCT      COINS        TOTAL      PROV PD  PROV    CHECK

        CLAIMS   AMT       AMT        AMT       AMT        RC-AMT      AMT    ADJ AMT   AMT

        1      1839.00     581.82        0.00        116.37       1257.18       465.45   152.64    312.81

PROV ADJ DETAILS:   PUB REASON CODE     FCN             HIC        AMT          

                          WO             1234567890123    XXXXXXXXXA       153.75
                           L6                                                -1.11

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.
 B6         This service/procedure is denied/reduced when performed/billed by this type of provider, by this type of provider in 
            this type of facility, or by a provider of this specialty.
 MA01       If you do not agree with what we approved for these services, you may appeal our decision.  To make sure that we are 
            fair to you, we require another individual that did not process your initial claim to conduct the review. However, 
            in order to be eligible for a review, you must write to us within 120 days of the date of this notice, unless you 
            have a good reason for being late.
 MA18       The claim information is being forwarded to the patient's supplemental insurer.  Send any quesions regarding
            supplemental benefits to them.
 L6         Interest
 WO         Withholding

Field Descriptions
Detail Fields: Per Prov: This field displays the beneficiary's name, the billing provider number, the rendering provider number, the patient responsibility heading, and some message codes. When checking the reason for denial make sure not to overlook this code. There may be remarks also in this field. These remark codes are important to incomplete claim rejections. For example: REM: M76. This code needs to be defined in the glossary.
Serv Date: This field provides the service from and to dates as well as the patient's responsibility.
POS: The place of service field contains a two digit number that references where the services were rendered.
NOS: The number of service field shows how many services were billed per procedure code.
Proc: The procedure code is located in this column as well as the patients Health Insurance Claim number (HIC) or the Medicare number.
MODS: If any modifiers were billed, they will be located in this field.
Claim Total Fields: Billed: This field also contains the billed amount per procedure. If the patient account number is reported on the claim, Medicare will display that number in this field.
Allowed: This column displays the allowed amounts per procedure. This amount is based on the Medicare Fee Schedule.
Deduct: If any deductible is applied the amount will show in this field. The Internal Control Number (ICN) will also appear in this column.
Coins: This is the coinsurance field. The amount of the beneficiary's coinsurance, 20% of the allowed amount, will be displayed here.
Group Reason Code(GRP/RC): Group codes represent the financially responsible party. Reason codes explain denials and payments. These combinations of codes are defined in the glossary at the bottom of the Standard Provider Remittance. An online reference is available by accessing . The MOA (Medicare outpatient adjudication remarks) code is the heading. This code does not display any adjustments or reasons. The codes following this heading explain the outcome of the claim, and also need to be defined in the glossary. Follow the steps below to access the codes: 1. Select HIPAA from the meny on the left hand side of the page 2. Select Code Lists from the menu 3. Select either Claim Adjustment Reason Code or Remittance Advise Remark Codes
Grp/RC-Amt: This column contains the type of assignment (ASG). A "Y" indicator shows the provider accepted assignment. A "N" indicator shows a non-assigned claim. Under the assignment indicator are the non-covered service amounts. These amounts will equal the difference between the billed amount and allowed amount. The last field in this column is a total of the non-covered amounts.
Prov. Pd: The amount paid per procedure is displayed in this field. Also the total amount paid on this claim is shown in this column. The claim total reported is the net payment. The MOA (Medicare outpatient adjudication remarks) code is the heading. This code does not display any adjustments or reasons. The codes following this heading explain the outcome of the claim, and also need to be defined in the glossary. You can also view a complete listing of these codes by accessing Reason Remark Codes on the provider internet site located beneath the Provider Information indicator.
Adj. To Totals: Adjustments are printed on the ADJs line.
Prev Pd: For full claim adjustments, the Prev Pd field represents the previous accumulative payment to the provider, on an original claim, and has the GRP/RC-AMT value OA-B13.
INT: This field represents the difference between the current interest on the adjustment claim and the previous interest from the original claim.
Late Filing Charge: This field represents the reduction taken when the claim was submitted more than 1 year after the date of service.
Claim Information Forwarded To: This represents the patient's secondary insurance carrier.
Net: This field represents the net amount for a given claim, which should be the actual amount being paid for that claim to the provider. This field does include interest.
Summary (Totals) fields: # Of Claims: Number of claims displayed on the SPR.
Billed Amt: Total amount billed on the SPR.
Allowed Amt: Total allowed amount on the SPR. This amount is based on Medicare’s Fee Schedule.
Deduct Amt: The total amount of the deductible applied on the SPR.
Coins Amt: Total amount of coinsurance on the SPR.
Total RC-Amt: Total amount of non-covered services. This is the difference between the total billed amount and the total allowed amount.
Prov. Pd Amt: The total amount paid on the SPR. This should be the check amount if no adjustments were made.
ADJS Fields: Prov Adj. Amt: The amount the check has been adjusted from the provider's paid amount.
Check Amt: The amount of the check.
Offset Fields Offsets to payments are shown as an adjustment from the provider's payment at the summary level rather than as an adjustment against an individual claim in that remittance notice.
PLB Reason Code: This field displays the reason for the offset. A two letter code is shown. The codes need to be defined in the glossary. AP = Advanced Payment. FB = Balance Forward. This can represent an amount under $1.00 which will be paid in the future. L6 = Interest applied. The difference between the original interest amount and the adjusted interested amount. 50 = Late filing reduction WO = Withholding Offset as a result of a previous payment CS = Adjustment - The amount paid on an original claim for full adjustments. This indicator may also be present when the provider is not participating or it may be present on a Medicare Secondary Payer Claim. B2 = Refund
FCN: The financial control numbers that associate the offset with those claims and payments that led to the withholding. FCN information is not applicable for L6 and 50.
HIC: The field displays the health insurance claim number of the patient who caused the offset. Multiple HIC numbers will not be printed. HIC information is not applicable for L6 and 50.
Amount: The amount being withheld or added.
Glossary: This is a guide to all the reason codes. Use remarks and codes in the claim detail and summary portions of SPR to determine the outcome of the claim. For complete details regarding the new Standard Paper Remittance, please check your MCS Transition News.
Full Claim Adjustments Remittance advice remark code MA67 indicates that a correction was made to a prior claim. If the adjusted claim payment amount is less than the payment on the original claim submission, then the NET amount is zero. A BF adjustment will be added to the PROV ADJ Detail Field reflecting this amount. When the offset occurs, the WO amount that is listed in the PROV ADJ Detail field should be subtracted from the amount listed in the PROV PD AMT field. This amount should be the amount listed in the CHECK AMT field.