Medicare - Some useful tips

Claim Status

Wait for the 14 day electronic and 29 day paper payment floor before calling-use the IVR system

Remittance Advice

Group Code meanings to assist providers in reading remittance advices

Payment Calculation

Medicare payment at 80% of the allowable, minus deductibles for a participating provider. Example: Charge $120
Allowed $100
Medicare Paid (80%) $80
Deductible/coinsurance amounts $20 (20%)

PR Patient Responsibility

This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary's behalf. The PR codes are used with the reason codes.
· Patient deductible or coinsurance
· Patient assumed financial responsibility for a service not considered reasonable
· Cost of therapy or psychiatric services after the coverage limit has been reached
· Charge denied because of the patient's failure to supply primary payer or other information
· Patient is responsible for payment of excess non-assigned physician charges

Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (Reason Code B4), excess charges on an assigned claim (Reason Code 42), services that are not reasonable and necessary for care (Reason Code 50 or 57), etc., are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

CO Contractual Obligation

This includes any amounts for which the provider is financially liable, such as participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, or medical necessity denials/reductions. The patient may not be billed for these amounts.

OA Other Adjustment

This would only be used if neither PR nor CO applied. At least one PR, CO or OA group will appear on each remittance statement. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.

Medicare codes

Medicare suffix codes

Medicare payment

Medicare billing

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