Remittance

Since early October I have noticed our practice has a considerable increase in the write-off amounts base on OA-209. Additionally, it does not appear as though deductible and copayments are being calculated correctly for some patients. Has something changed?

Answer: On October 2, 2017, Medicare Administrative Contractors (MACs) began using Group Code OA (other adjustment) and Claim Adjustment Reason Code (CARC) 209. (Per regulatory or other agreement, a provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected.)

This informational CARC allows providers to identify a beneficiary enrolled in the Medicaid/Qualified Medicare Beneficiary (QMB) program and that the patient has no Medicare cost-sharing liability. CARC 209 indicates amounts identified may be billed to subsequent payers. Some providers’ accounting systems or software protocol may be automatically writing off these amounts. Providers will need to research their individual write-off procedures and software protocols. 

Note: There is no issue with Medicare payments or application of copayments and deductible on these claims. Palmetto GBA is unable to assist providers with reconciling QMB patient accounts. Questions about Medicaid payments and write-off amounts must be directed to Medicaid.

Full details are outlined in CMS MM9911 (PDF) and CMS SE1128 (PDF).

Last Reviewed: 9/18/2024

The "WU" indicates that an unspecified recovery has been applied toward your payment. This was not initiated through a Medicare Part B overpayment. Call the IRS telephone number on the Medicare remittance notice, 800–829–7650 or 800–829–3903, for more information. Have your tax identification number available when calling.

Last Reviewed: 9/18/2024

Remark code J1 indicates that Palmetto GBA no longer considers that service to be an overpayment. Because Palmetto GBA initially paid the service, and we never collected an overpayment for that service, we are not issuing a new payment. This remark code shows that we are changing the "status" of that service from "overpayment" to not an overpayment. The J1 message informs you that payment has been suppressed.

Last Reviewed: 9/18/2024

CARCs and RARCs are codes used on the Medicare provider remittance advice (RA) to explain any adjustment(s) made to the payment. 

CARCs, or Claim Adjustment Reason Codes, explain financial adjustments, such as denials, reductions or increases in payment. CARCs explain why a claim (or service line) was paid differently than it was billed. CARCs are used in the RA with group codes that shows the liability for amounts not covered by Medicare for a claim or service. Group codes include CO (contractual obligations), OA (other adjustments) and PR (patient responsibility). CARCs can be reported at the service-line level or the claim level. 

Example

• CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an alert.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARCs, or Remittance Advice Remark Codes, are used in the RA in conjunction with CARCs to further explain an adjustment or relay informational messages that cannot be expressed with a claim adjustment reason code. Most RARCs are supplemental and further explain an adjustment already described by a CARC. Other remark codes are informational and do not further explain a specific adjustment but provide general adjudication information. Informational remark codes start with the word "Alert." RARCs can be reported at the service-line level or the claim level. 

Examples

• RARC MA120: Missing/incomplete/invalid CLIA certification number. RARC MA120 could be used to further explain CARC/Group Code CO-16
• Informational RARC MA15 — Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported

Resource: IOM 100-04, Medicare Claims Processing Manual, Chapter 22, Section 60 (PDF)

Last Reviewed: 9/18/2024

"Forwarding balance" means that a negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous Remittance Advice (RA). A reference number (the original ICN and the patient's Medicare ID number) is applied for tracking purposes.

What Does That Mean?

• A negative value represents a balance that will be moved forward to a future remittance payment advice. This means that an overpayment for a specific claim or claims (on this remittance) has been created because Medicare has paid for a service that should not have been allowed or has paid too much for a service. Your remittance notice will show the corrected allowed amounts for the adjusted claim(s).
• A positive value represents a balance that is being applied from a previous remittance advice. This means we are notifying you that we have completed an adjustment on a claim or claims (included in this remittance) and we have determined that an additional payment is due in part or in full for a previously processed service(s). Your remittance notice will show the corrected allowed amounts for the adjusted claim(s). A reference number (the original ICN and the patient's Medicare ID number) will be provided for tracking purposes.

Last Reviewed: 9/18/2024