Standard Paper Remittance Advice Notice Revisions
Several improvements are detailed below to ensure that the format of the Standard Paper Remittance (SPR) Advice Notice corresponds to the Electronic Remittance Advice (ERA) changes for the Health Insurance Portability and Accountability Act (HIPAA). The effective dates are:
- April 1, 2002 for Illinois, Michigan and Wisconsin
- July 1, 2002 for Minnesota
SPR Format Changes
An example of the revised "general" format for the SPR follows. The highlights include:- The Patient Account field on the SPR is expanded to 20 bytes.
- Provider offsets will be reported using 4010 mnemonics (see below). The mnemonics will report to the glossary section. The glossary section will be renamed to:
- "AMOUNT PAID TO BENEFICIARY" and "MSP AMOUNT" fields used to compute provider payment will now be reported as reason code adjustments, rather than in separate fields.
- There is a new claim level field for the informational reporting of late filing reductions.
- There is space to provide the submitted HCPCS code and the paid HCPCS code at each service line.
- The "TOTAL OFFSET" field has been renamed as "PROVIDER ADJ"
- The "TOTAL PAID TO BENEFICIARY" and "TOTAL OTHER ADJUSTMENTS" fields have been deleted at the provider level.
SPR Balancing
As with an ERA, the amounts reported in an SPR must balance at the transaction, the claim and the service line levels, following these formulas:Service line level balancing:
Submitted line charge -- Sum of service level Reason Code amounts = Prov Pd (Calculated payment to provider)
Claim level balancing:
Billed (submitted claim level charge) -- Sum of all service level Reason Code amounts = Prov Pd (calculated payment to provider at the claim level)
Transaction level balancing:
Sum of all Prov. Pd amounts in the claim segments -- Total provider adj. = Amount of check
General SPR Information
- The computed field "NET" must include "PROV PD," "INTEREST," "LATE FILING CHARGE," and "PREV PD" amounts.
- Only the name of the first supplemental, crossover insurer on our file will show in the "CLAIM INFORMATION FORWARDED TO:" field. This is true even if the beneficiary has more than one supplemental insurer.
- The amount of your check is the sum of all claim level payments less any provider level adjustments.
- Positive adjustment amounts reduce the amount of the payment and negative adjustment amounts increase it.
- On an SPR for an adjusted claim, the "PREV PD" field will show the amount paid on the original, voided claim when Full Claim Adjustment is implemented.
4010 MNEMONICS |
|
| J1 | Adjustment Used to zero balance provider payment for Centers of Excellence Remittances and Medicare Choices Remittances. |
| AP | Advance Payment |
| WO | Offset as a result of a previous overpayment |
| L6 | CPT interest accrued If the net interest is added to the "TOTAL PROV PD" amount, then the offset detail will be a negative number. If it is subtracted from the "TOTAL PROV PD" amount, then the offset detail will be a positive number. |
| 50 | Late Filing If the net late filing is subtracted from the "TOTAL PROV PD" amount, then the offset detail will be a positive number. If the net late filing is added to the "TOTAL PROV PD" amount, then the offset detail will be a negative number. |
| B2 | Refund |
| FB | Balance Forward
|
A crosswalk of the SPR data fields to the 835V4010 data fields is provided after the sample SPR.
Link to Sample SPR:
Sample SPR* (pdf)
Link to SPR Crosswalk:
SPR Crosswalk to 835V4010--Carriers* (pdf)
*To read these documents, you will need to have an Adobe Reader installed on your system. You may download a free reader from the Adobe site by clicking here.
Page Last Updated: Tuesday, 04-Dec-2007 13:19:17 CST
