RA Companion Guide
The purpose of this guide is to outline the format and layout of the RA to assist in reviewing claims status within a checkwrite period.
RA Layout explained
The RA is grouped by four adjudication decisions: Approved claims, Denied claims, Sub-Capitated claims and then by Recoupments (Credit Memos). From within each adjudication group, there are sub-groups broken down by funding source (State or Medicaid). From within the funding source grouping, it is then sub-grouped by consumer. Then lastly with in the consumer grouping, claims are in order by date of service, with subtotals under each grouping.
RA Outlined: Grouping is visualized as below
1)Paid Claims
a)State Claims
i)Consumer
(1)Date of Service
b)Medicaid Claims
i)Consumer
(1)Date of Service
2)Denied Claims
a)State Claims
i)Consumer
(1)Date of Service
b)Medicaid Claims
i)Consumer
(1)Date of Service
3)Sub-Capitated Claims
a)State Claims
i)Consumer
(1)Date of Service
b)Medicaid Claims
i)Consumer
(1)Date of Service
4)Recoupments(Credit Memos)
a)State Claims
i)Consumer
(1)Date of Service
b)Medicaid Claims
i)Consumer
(1)Date of Service
RA Break Down(TOP)
Header Information: The RA header displays core MCO and payment information such as contact information, check number, check amount claims type and processing dates.
Claim Field Labels: at the top of every page, there is a frozen pane that identifies what each data element on the claim represents. It will look as below:
Paid Claims(TOP): Below is an example of a paid claim. Notice how all three claims came in on the same claim header, but broken down per claim line. Since adjudication is at the claim line level, then this claim is viewed as 3 separate claims on the RA.
In the above example, you’ll notice that 6 units were billed per day. Although each claim line was approved, you’ll notice that the paid amount was adjusted due to claimed amount is higher than the contract amount.
Billed Amount ($417.00) - (6 units * contract rate of $31.41) = Adjusted amount $228.54 to pay $188.46. Under the reason codes, 2 meaning the clam was approved after adjusting paid amount to equal the contract rate (indicated using the number one).
Since the funding sources are grouped, you’ll have a subtotal for State Claims and a sub total for Medicaid claims.
Denied Claims(TOP): Denied claims are also grouped together as well as broken out by funding source with it’s own sub total. On the claim line that denied, the denial code is also listed. Reason codes are defined at the end of the RA to assist in working denials. In this example the denial reason is 25 which is for “Invalid POS & Service Combo.”
Shown below is the sub total of denied claims for State services which is listed earlier in this sample RA. This will show you the numbers to get the total amount above in gray:
Sub Capitated Claims(TOP): sub capitated claims are listed in the next section of the RA. This will look very much like Fee for Service claims except a dollar amount will be indicated in the subcap field as listed below:
**Note: Do not let the denied amount dupe you. This is basically stating that the FFS paid amount is “denied” because the provider is already being paid for the service and the encounter claim submitted was approved at the contracted rate. Claim was adjusted to the contracted rate. (Contract rate * 4 = $78.68. )
Recoupments (Credit Memos)(TOP): the last grouping of claims are where recoupments and credit memos are identified. Each line will display the claim where a recoupment or CM was applied as well as identify the source claim from where the CM came from:
The highlighted verbage explains exactly what happened: “The payment for Clm_adj_ID A was used to reconcile a CM created for the recoupment of Clm_adj_ID B which was originally paid by a previous CM. This transaction satisfied 79.24 of the 79.24 CM.”
Reason Code Key(TOP): towards the end of the RA immediately under the grand totals for the RA, is a reason code key that assists in identifying why a claim denied. The listed denial reasons are not all of the MCS denial reasons, but a list of denial reasons on the RA you are looking at. So the below list of denial reason are currently on this sample RA:
Field Descriptions(TOP): at the very end of the RA, field descriptions are listed to assist in navigating and reconciling the RA.
1 / AlphaCM, Inc30-Sept-13