Provider Web Portal Quick Guide – Reading the Remittance Advice (RA) Dated on or After 1/9/2019

Last updated: 09/15/2020
 

Introduction

The Financial Transactions page has been updated to provide additional payment and recoupment information to further assist providers in reconciling RAs.

For RAs prior to 1/9/2019, refer to Reading the Remittance Advice (RA) Dated Before 1/9/2019 Quick Guide.

RA Sections and Page Numbering

The downloadable PDF RA file will not include every page that is included in the printable RA.

Address Cover Page (Page 1): The Address Cover Page will never appear in the PDF file, as it is used if mailing an RA.

Banner Message Section (Page 2): Any important messages from the Department of Health Care Policy & Financing (the Department) will appear on page 2.

Payment Notice Section: The Payment Notice section will never appear in the PDF file, as it is used for printing a physical check or EFT notice when mailing an RA.

Interpreting Claim Numbers

Each claim and adjustment is assigned a unique claim number, known as the internal control number (ICN). The following diagram and table provide detailed information about interpreting the claim number.

breakdown of ICN number

 

Type of Number and Description Applicable Number and Description
Region – The first two digits indicate how Health First Colorado received the claim or adjustment request. 10 – Paper Claims with No Attachments
11 – Paper Claim with Attachments
20, 21 – Batch Claim
22 – Web Portal Claim with No Attachments
23 – Web Portal Claim with Attachments
25 – PBM Pharmacy Claims
30, 31, 40 – Claims Converted from Old MMIS 50 – Provider Initiated Adjustment (via paper)
51, 52, 53, 55, 57, 58 – System Initiated Adjustments
54 – Mass Void
56 – Mass Void Request or Single Claim Void
59 – Provider Initiated Electronic Adjustment
80 – Claim Resubmission by DXC
94 – Web Portal Reconsideration Claims with Attachments (Note: If OZ is used for attachment, this region code indicating reconsideration will be automatically assigned, even if a reconsideration is not indicated by the provider.)
95 – Provider Initiated Web Portal Reconsideration Adjustment with Attachments
Year – Two digits indicate the year the claim was received. For example, the year 2017 would appear as 17.
Julian Date – Three digits indicate the day of the year, by Julian date, that the claim was received. For example, February 3 would appear as 034.
Batch Range – Three digits indicate the batch range assigned to the claim. The batch range is used internally by Health First Colorado and is not applicable to providers.
Sequence Number – Three digits indicate the sequence number assigned within the batch range. The sequence number is used internally by Health First Colorado and is not applicable to providers.

 

Adjustments and Recoupments

Providers will see a Claim Adjustments section in the Remittance Advice (RA) if any of their claims were adjusted during the current financial cycle.

  • Adjustments can be provider initiated or system generated (refer to region codes above).
  • Recoupments are generally done on the same RA as the adjusted claim. See Scenario 1, Figures 1-3.
    • Exception: Provider does not have enough paid claims to satisfy the recoupments. If the recoupment amount exceeds the paid claim amount, the recoupment will continue to the next weeks’ RA until the total amount is recouped. See Scenario 2, Figures 4-7 for more information.
  • Claim information will appear in the adjustment section for each claim type.
  • Additional payment or overpayment to be withheld will be listed for each adjustment.

See the Claim Adjustment section in the figure below for Scenario 1.

RA Claim Adjustment - Additional Payment
Figure 1 . RA Claim Adjustment - Additional Payment

See the Claim Adjustment section in the figure below for Scenario 2.

RA claim adjustment – overpayment to be withheld
Figure 2 . RA Claim Adjustment – Overpayment to be Withheld

Financial Transactions Page

Adjustment Summary:

  • Total No. Adj - The total number of adjusted claims on the RA.
  • Total Additional Payments - Additional amount owed to the provider as the result of claim adjustments.
  • Total Payment to be Withheld - Additional amount owed by the provider as the result of claim adjustments.
  • Total Refund Amount Applied - Amount of a cash receipt received from the provider applied to cash related claim adjustments.

Non-Claim Specific Payouts to Payee section:

  • Transaction Number
  • Payout Amount
  • Service From and Date Thru
  • Related Provider ID
  • Reason Code - This is four-digit code used to identify the Expenditure Reason.
  • Expenditure Reason - This is the reason an expenditure (check/payment) was generated. (See Appendix S for the list of Expenditure Reason Codes and their description.)
  • Total Payouts

Non-Claim Specific Refunds from Payee section:

  • Refund Transaction Number
  • Refund Amount
  • Check/EFT Number
  • Receipt Date
  • Reason Code - This is a four-digit code use to identify the Cash Disposition Reason.
  • Cash Disposition Reason - This is the reason for the Cash Disposition.
  • Total Refunds

The Accounts Receivable (AR) section provides information on recoupments under "Payee Recoup Percentage" and "Payee Recoup Amount" and a list of all outstanding ARs. The AR may be partially recouped or not recouped at all which will be indicated by these two fields. A recouping restriction is an established guideline in Colorado interChange that limits or prevents the automatic recovery of all monies owed on an AR when there are available provider funds.

The only recouping restriction displayed on the RA is the Payee Max Recoup restriction, where the payee is the provider. This restriction is displayed in the following fields:

  • Payee Recoup Percentage - The maximum percentage of a provider’s payment that can be used to recover monies owed to Health First Colorado in that payment cycle.
    OR
  • Payee Recoup Amount - The flat, maximum amount to recover up to, but not exceeding the payment due to the provider.

If there is a Payee Max Recoup restriction in place for the provider, the "Payee Recoup Percentage", "Payee Recoup Amount", "AR Effective Date" and "AR End Date" fields are specified.

If there is no Payee Max Recoup restriction in place, the "Payee Recoup Percentage" field will read 100% and all of the monies paid to the provider in that payment cycle can be used to recover monies owed to Health First Colorado.

Note: Any existing agreement between the provider and the Department regarding specific accounts receivables owed will be honored regardless of these recouping restrictions.

Below the Payee Recoup fields, the following information is displayed for each outstanding AR. Fields are defined below and highlighted in Figure 2:

  • A/R Number - The Accounts Receivable section includes Manual, Repayment and outstanding Automatic ARs without current cycle activity.
  • Setup Date
  • Previous ICN
  • Original A/R Amount - This is the original accounts receivable setup amount.
  • Recouped in Current Cycle
  • Balance
  • Adjustment ICN
  • Adjustment Amount - This is the amount paid on the adjusted claim.
  • Member Number - Member ID
  • DOS From - This is the first date of service on the claim.
  • DOS To - This is the last date of service on the claim.

See the Financial Transactions page in the figure below for Scenario 1.

RA Financial Transactions - Initial AR Setup
Figure 3 . RA Financial Transactions - Initial AR Setup

See the Summary page in the figure below for Scenario 1.

RA Summary
Figure 4 . RA Summary

See the Financial Transactions section in the figure below for Scenario 2.

RA Financial Transaction – Initial AR Setup
Figure 5 . RA Financial Transaction – Initial AR Setup

RA Financial Transaction – AR Withholding
Figure 6 . RA Financial Transaction – AR Withholding

RA Financial Transaction – AR Withholding
Figure 7 . RA Financial Transaction – AR Withholding

Recognizing Co-pay

Co-pay represents the amount of member responsibility on a claim detail that is to be collected by the provider at the time the service is rendered.

Co-pay appears on the RA as "COPAY AMT" for the following RA types:

  • Dental Claim Adjustments
  • Dental Claims Paid
  • Professional Service Claim Adjustments
  • Professional Service Claims Paid
  • Compound Drug Claim Adjustments
  • Compound Drug Claims Paid
  • Drug Claim Adjustments
  • Drug Claims Paid
  • Inpatient Claim Adjustments
  • Inpatient Claims Paid
  • Outpatient Claim Adjustments
  • Outpatient Claims Paid
  • Medicare Crossover Institutional Claim Adjustments
  • Medicare Crossover Institutional Claims Denied
  • Medicare Crossover Institutional Claims Paid
  • Medicare Crossover Professional Service Claim Adjustments
  • Medicare Crossover Professional Service Claims Paid

co-pay amount on a dental claim

co-pay amount on an outpatient claim

Co-pay appears on the RA as "COPAY" for the following RA types:

  • Remittance Advice - Medicare Crossover Professional Service Claims Denied
  • Remittance Advice - Medicare Crossover Professional Service Claims In Process

co-pay amount on Medicare crossover claim

Co-pay appears on the RA as "COPAY AMOUNT" for the following RA types:

  • Remittance Advice - Outpatient Claims Denied

co-pay amount on Outpatient Claims Denied

Summary Page

The RA Summary page provides Claims Data totals; information on Payments to Lien Holders; Earnings Data totals; and information Outstanding, Expiring, Expired paper checks.

The Summary Page includes notifications that appear when a provider has received a payment for claims, refund, capitation agreement, etc. by paper check and that check is expiring or expired.

Notifications on the status of any uncashed, paper checks are displayed on the RA under one of three categories:

  • Outstanding Checks (Checks within 90 days to six weeks of expiration) – A notification appears on all RAs generated until the check moves to the next status (Expiring) or is cashed or voided.
  • Expiring Checks (Checks within six weeks of expiration) – A notification appears on all RAs generated until the check is expired, cashed or voided.
  • Expired Checks (Checks beyond the 180 day "Void by" expiration date printed on the check. They are no longer eligible to be cashed by the bank.) – A notification appears once on the next RA generated for the provider.

See the example below.

summary page

Using a Comma-Separated Values (CSV) File

The RA is available for download as PDF and CSV file formats. Downloadable CSV-formatted RAs allow users the benefits of building a customized RA specific to their use and saving the file to their computer. The CSV file on a provider's Web Portal appears as linear text separated by commas until it is downloaded into a compatible software program. Once downloaded, the file may be saved to a user's computer and the data manipulated, as desired.

To access the CSV file, providers should select the "Search Payment History" option from the left side of the provider’s Web Portal home page. From the Search Payment History page providers can search for a given payment. The RA CSV file is listed for each payment returned in the search. The provider can click on the icon under the RA Copy (Delimited) column to download the CSV file.

Formats include:

  • Microsoft Office Excel
  • Microsoft Office Access
  • OpenOffice 2.2.1 — free software program available

Free spreadsheet applications can be found at:

  • Google Docs
  • ZDNet

Need More Help?

Please visit the Quick Guides web page to find all the Provider Web Portal Quick Guides.