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Remittance Advices and Recoupments
March 8th, 2018
Trevor Abeyta Rates Operations Section
Our Mission
Improving health care access and
- utcomes for the people we serve
Recoupments March 8th, 2018 Trevor Abeyta Rates Operations Section - - PowerPoint PPT Presentation
Recoupments March 8th, 2018 Trevor Abeyta Rates Operations Section - - PowerPoint PPT Presentation
Remittance Advices and Recoupments March 8th, 2018 Trevor Abeyta Rates Operations Section Our Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources Purpose of
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Purpose of Presentation
- 1. Why claim and capitation adjustments occur
- 2. Learn about recoupments
- 3. Determine if a remittance advice has had a recoupment
- 4. Questions
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Types of Adjustments
- Claim Adjustments
- Capitation Adjustments
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Claim Adjustments
- Why do claim adjustments occur?
- System changes and configurations
- Annual legislative rate changes
- How do claim adjustments work?
- Entire claim is taken back and then repaid with any changes in
reimbursement if they occurred
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Capitation Adjustments
- Why do capitation adjustments occur?
- Per Member Per Month Attribution Reconciliation
- How do capitation adjustments work?
- Capitations are not claims based
- Entire capitation is taken back
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Recoupments
- Adjustments resulting in recoupments will take money back
until the AR balance is satisfied
- Claims based recoupments can cross into capitation/PMPM cycles
- Capitation based recoupments can cross into claim cycles
- Systems change request to align recoupment with the type of
financial cycle
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Example 1: Claims Cycle
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Claims Paid Line
- Claims paid which were billed this cycle
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Claim Adjustments Line
- Claims adjusted from previous cycles
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Total Claims/Claim Payments Lines
- Total amount paid from the current and previous cycle after
adjustments
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AR Section
- Current Cycle: Total claim adjustments from the current cycle
- Outstanding From Previous Cycle: Recoupments from previous
cycles
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Net Payment/Earnings Lines
- Total amount for claims billed this cycle minus any claims
adjusted this cycle.
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Claim Adjustments Section
- Amount being adjusted from the current cycle
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Example 2: Capitation Cycle
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Capitation Payment Line
- Attributed member PMPM paid this capitation cycle
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AR Section
- Non-Claim Specific Line: Capitation/PMPM Adjustments
- Claim Specific: Outstanding AR from Claims Cycle
- Important if claims recoupments ran over into the capitation/PMPM
cycle
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Capitation Net Payment/Net Earnings
- Total amount paid this capitation cycle minus any
capitation adjustments and leftover claims adjustment ARs
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Financial Transactions
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Financial Transactions
- A/R Number Ranges
- 350000000 – 499999999 – Physician Claim Adjustments
- 700000000 – 799999999 – Capitation Adjustments
- Remember: Capitations not claims based
- Capitations do not have ICN Numbers
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AR Number Ranges
- 000000000 – 099999999 – Manually created ARs
- 100000000 – 249999999 – UB92 Claim Adjustments
- 250000000 – 349999999 – Dental Claim Adjustments
- 350000000 – 499999999 – Physician Claim Adjustments
- 500000000 – 699999999 – Pharmacy Claim Adjustments
- 700000000 – 799999999 – Capitation Adjustments
- 800000000 – 899999999 – Incentive Adjustments
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Helpful RA Tips
- If Check/EFT is all zeros no financial
transaction was made
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Helpful RA Tips
- If the first total recoupment line is a larger
number than the second it is likely a runover AR Balance from a previous cycle
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Questions?
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Contact Information
Any additional questions please contact:
Corey Wong Business Analyst corey.wong@state.co.us Trevor Abeyta Rates Analyst trevor.abeyta@state.co.us
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