After you receive the paper Remittance Advice (RA)

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After you receive the paper Remittance Advice (RA)

• Department of Human Services

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About the RA

• The paper Remittance Advice (RA) tells the
  provider about payment or other claims actions
  made by DHS.
• You can only take actions on claims that appear
  as adjudicated or denied (not in process) on
  the RA.
• The claim lists the header and/or detail
  Explanation of Benefit (EOB) codes that explain
  actions taken by DHS.
• Refer to the last page of your RA (EOB
  Descriptions) for what these codes mean.

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How it works for claim submissions
Claim received
Claim generates through the
Medicaid
Management Information System (MMIS)
Meets payment criteria
Does not meet payment criteria
A Remittance Advice is generated
Claim Paid
Claim Partial Paid
Claim Denied
Claim in Process
Do not resubmit claim. If needed,
complete a DMAP Individual Adjustment Request
form (DMAP 1036) or adjust the claim via the Web
portal.
If needed, correct claim and resubmit, on paper
or via the Web portal
No action needed. Wait for DHS resolution.
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Paid claim example

• This claim shows 2 lines of services billed DHS
  approved and paid both lines.
• The detail EOBs indicate why DHS paid these
  amounts
• EOB 9920 PRICING ADJUSTMENT - RBRVS PRICING
  APPLIED.
• EOB 9918 PRICING ADJUSTMENT - MAX FEE PRICING
  APPLIED.
• If the claim paid incorrectly, or you billed
  incorrectly, you would adjust the claim on paper
  (DMAP 1036) or the Provider Web Portal.

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Partial-paid claim example

• This claim shows 6 lines of services billed. DHS
  paid for 3 lines.
• The EOBs on the zero-paid lines (circled)
  indicate why DHS did not pay.
• EOB 9926 is informational CLAIM HAS CUTBACK
  AMOUNT (provider billed more than DHS will pay).
• EOB 0015 says that the SERVICE IS A DUPLICATE OF
  A SERVICE PREVIOUSLY PROCESSED/PAID.
• EOB 9940 is informational PRICING ADJUSTMENT -
  PROVIDER PERCENT BILLED APPLIED.
• To correct the lines that didnt pay, adjust on
  paper or the Provider Web Portal.

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Denied claim example

• On this claim, all lines denied due to EOB 0090 -
  SERVICE IS COVERED BY A MANAGED CARE PLAN. CLAIM
  MUST BE BILLED TO THE APPROPRIATE MANAGED CARE
  PLAN.
• If this information is incorrect, you would need
  to correct and resubmit the claim to DHS.

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Zero-paid claim example
100.00
0.00
1136
1136

• On this claim, both services zero paid because
  other insurance (third-party liability, or TPL)
  paid above the DHS-allowed rate for the service.
• Detail EOB 1136 NO PAYMENT MADE - TPL/SPENDDOWN
  IS MORE THAN THE ALLOWED AMOUNT.
• If you billed this claim incorrectly
• Do not resubmit the claim (it will deny as a
  duplicate).
• Instead, adjust the claim on paper or the
  Provider Web Portal.

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Overpayments, adjustments, refunds and recoupments
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Overview

• When you notice overpayments on your RA, you have
  two options
• Adjust each overpaid claim individually on paper
  (DMAP 1036) or the Provider Web Portal.
• Send DMAP a refund for all the claims that
  overpaid on the RA, with a copy of the RA that
  indicates the overpaid claims.
• Only do one of these options not both!

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How to adjust a claim

• To adjust overpaid and underpaid claims
• On paper
• Complete the DMAP 1036 (Individual Adjustment
  Request) at http//dhsforms.hr.state.or.us/Forms/S
  erved/OE1036.pdf.
• Include a copy of the RA and a corrected claim,
  if needed.
• On the Web
• Go to the Provider Web Portal at
  https//www.or-medicaid-gov.
• You cannot adjust denied claims.
• Instead, correct and resubmit denied claims on
  paper or on the Provider Web Portal.

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How to submit a refund

• Write DMAP a check and mail it to
• DMAP
• PO Box 14955
• Salem, OR 97309
• Include the following
• A copy of the RA
• A letter addressed DHS Receipting Specialist,
  HSB 4th Floor explaining the reason for the
  refund
• Any related correspondence leading up to the
  refund

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Recoupments

• DHS will recoup overpayments from future RAs
  when
• You adjust an overpaid claim, or
• You do not reply to correspondence about an
  overpayment.
• Recoupment information will display on your RA as
  follows
• After the adjustment, the detail EOB in the
  Adjustments section of your next RA will indicate
  0078 - ADJUSTMENT RESULTED IN REDUCED PAYMENT.
  ACCOUNTS RECEIVABLE SET-UP FOR REMAINDER.
• Until the overpayment is fully recouped, the
  Financial Transactions page of future RAs will
  track the amount recouped by DHS each week, and
  the remaining balance.
• Recoupments will be tracked by the ICN of the
  adjusted claim.

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Resources
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Need help?

• To stop receiving paper RAs or get help reading
  the RA
• DMAP Provider Services
• 800-336-6016 or dmap.providerservices_at_state.or.us
  
• To view claim status and adjust or resubmit
  claims on the Web
• Provider Web Portal at https//www.or-medicaid.gov
  
• Read the paper and Web claim adjustment
  instructions
• www.oregon.gov/DHS/healthplan/tools_prov/tips/main
  .shtml

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Thank you!