Financial Transactions and Remittance Advice

1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE MODULE Financial Transactions and Remittance Advice LIBRARY REFERENCE NUMBER: PROMOD00006 PUBLISHED: DECEMBER 12, 2017 POLICIES AND PROCEDURES AS OF S EPTEMBER 1, 2017 VERSION: Copyright 2017 DXC Technology Company. All rights reserved. Library Reference Number: PROMOD00006 iii Published: December 12, 2017 Policies and procedures as of September 1, 2017 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of October 1, 2015 Published: February 25, 2016 New document FSSA and HPE Policies and procedures as of August 1, 2016 (CoreMMIS updates as of February 13, 2017) Published: April 6, 2017 Scheduled update FSSA and HPE Policies and procedures as of September 1, 2017 Published: December 12, 2017 Scheduled update.

2 Edited and reorganized text as needed for clarity Replaced Hewlett Packard Enterprise references with DXC Technology Made updates to Table 1, including the following: Moved RA subheads to the third column Updated descriptions for fields 10, 11, 24, 35, 40, 70, 71, and 79 Swapped fields 70 and 71 (and made corresponding updates to Figures 2 6 and 8 11) Removed ARC 178 from Table 3 Corrected callouts in Figures 2, 7, 10, and 11 in the Remittance Advice Examples section Removed the reference to transfer letter in step 4 in the Recovery of Accounts Receivable section Specified in the Accounts Receivable Referrals section that the transfer letter is sent to the pay-to address Updated Figures 20 and 21 in the Accounts Receivable Referrals section Updated Figure 22 in the Partial Payments and Repayment Agreements section FSSA and DXC Financial Transactions and Remittance Advice Revision History iv Library Reference Number: PROMOD00006 Published.

3 December 12, 2017 Policies and procedures as of September 1, 2017 Version: Version Date Reason for Revisions Completed By Updated the How to Enroll in the IHCP Electronic Funds Transfer Option section Reorganized and clarified text in the How to Cancel EFT Participation or Change EFT Information section Specified in the B-Notice Process section that documents are sent to the home office (legal) address Library Reference Number: PROMOD00006 v Published: December 12, 2017 Policies and procedures as of September 1, 2017 Version: Table of Contents Introduction.

4 1 Provider Remittance Advice .. 1 Remittance Advice Overview .. 2 Remittance Advice Section Descriptions .. 2 Remittance Advice Claim Sorting Sequence .. 4 Remittance Advice Field Definitions .. 4 Explanation of Benefits Codes .. 17 Adjustment Reason Codes .. 18 Adjustment Remark Codes .. 19 Summary Page .. 20 Remittance Advice Examples .. 23 Comparison of the 835 Transaction and Remittance Advice .. 44 Accounts Receivable, Financial Transactions , and Other Provider-Level Adjustments .. 44 Establishing Accounts Receivable .. 44 Accounts Receivable Reason Codes.

5 44 Recovery of Accounts Receivable .. 46 Accounts Receivable Referrals .. 47 Additional Provider-Level Adjustments .. 51 IHCP Payment Check Processing .. 56 Stop Payment and Reissue Requests .. 56 Stale-Dated Checks .. 57 Voiding an IHCP Payment Check .. 57 Electronic Funds Transfer .. 58 How to Enroll in the IHCP Electronic Funds Transfer Option .. 58 How an EFT Is Established with the Provider s Bank .. 59 EFT Rejections .. 59 How to Cancel EFT Participation or Change EFT Information .. 60 Refunds to the IHCP .. 60 Documentation Required.

6 60 Where to Send Checks .. 61 Internal Revenue Service Reporting Requirements .. 62 1099 Reporting .. 62 1099 Correction Requests .. 62 B-Notice Process .. 62 Library Reference Number: PROMOD00006 1 Published: December 12, 2017 Policies and procedures as of September 1, 2017 Version: Financial Transactions and Remittance Advice Introduction The most significant tool the Indiana Health Coverage Programs (IHCP) provider has to monitor participation in the program is the weekly Remittance Advice (RA). The RA statement provides information about claim processing and Financial activity.

7 To assist providers in using this tool, this document provides a copy of an RA with a detailed description of each field. In addition to claim adjudication, a variety of Transactions unrelated to a particular claim affects providers. These Transactions are referred to as non-claim-specific Financial Transactions . This document outlines the different Transactions , how each transaction is handled, and where the transaction appears on the weekly RA. This document also includes information about the following topics: Electronic funds transfer (EFT) Stop payments and reissuance of IHCP checks Voids of IHCP checks Accounts receivable (A/R) Internal Revenue Service (IRS) reporting requirements Note: The procedures in this document pertain to nonpharmacy services provided within the fee-for-service (FFS) delivery system.

8 Questions about Financial Transactions related to FFS pharmacy services should be directed to OptumRx. Questions about Financial Transactions related to members enrolled with a managed care entity (MCE) in the managed care delivery system should be directed to the MCE. MCE and OptumRx contact information is available in the IHCP Quick Reference Guide at Provider Remittance Advice The IHCP Financial cycle runs every Friday. Payments are calculated based on paid claims, less payments for outstanding accounts receivable and liens.

9 Check payments are dated for the Wednesday following the Financial cycle. EFT payments are deposited to the provider s designated bank account each Wednesday following the Financial cycle. RA statements about the status of processed claims and payment detail are available to providers via the IHCP secured website, the Provider Healthcare Portal (Portal) at The Portal posts the weekly RA online after the Financial cycle processes. Providers should access the Portal each week to download and save RAs for review. All prior RAs (from February 21, 2017, onward) are also stored on the Portal and are available for review at any time.

10 See the Provider Healthcare Portal module for information about registering for and using the Portal. Financial Transactions and Remittance Advice 2 Library Reference Number: PROMOD00006 Published: December 12, 2017 Policies and procedures as of September 1, 2017 Version: Providers can request a paper RA from the Written Correspondence Unit in the following ways: Submit the request through the Portal using secure correspondence. Email the request to Mail the request either on provider letterhead or using the Indiana Health Coverage Programs Written Inquiry form, available on the Forms page at , to the following address: DXC Written Correspondence Box 7263 Indianapolis, IN 46207-7263 To receive RA information through the 835 Health Care Claim Payment/ Advice electronic transaction, providers are required to complete the necessary trading partner profiles and agreements.