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Section X

SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers

1

sample check voucher

ADJUSTMENT BALANCE DUE AS OF LAST ACTIVITY ON 03/14/2006

ADJUSTMENT AMOUNT OWED 0.00

LESS MANUAL ADJUSTMENTS 0.00

NET BALANCE OWED PRIOR TO APPLICATION OF TODAY'S ACTIVITY 0.00

TOTAL PAYMENTS (SEE POSITIVE AMOUNTS PAID ON NOTICE OF PAYMENT) 43.97

LESS TODAY'S ADJUSTMENTS (SEE NEGATIVE AMOUNTS PAID ON NOTICE OF PAYMENT) 0.00

TOTAL ACTIVITY 43.97

PLUS FUNDS RETURNED TO CLEAR ADJUSTMENT BALANCE(S) 0.00

LESS NET BALANCE OWED PRIOR TO APPLICATION OF TODAY'S ACTIVITY 0.00

CHECK AMOUNT PAID TO TRI-CITY CONSULTANTS 43.97

activity summary

CB208X 04/30/04

DATE: 03/21/2008

PAYEE NUMBER: 860511234-002

CHECK NUMBER: 5272123

2060 East Ninth StreetCleveland, Ohio 44115-1355


National City Bank, AshlandAshland, Ohio 56-389

412

Check No.5272123

voiD

aFter

365

Days

Pay

To The Order Of :

Forty three Dollars aND 97/100 ceNts

Date of check03-21-2008

$******43.97*Exact Amount

VOID VOID

VOID VOID

VOID VOID

VOID VOID

VOID

TRI-CITY CONSULTANTSPO BOX 29123CLEVELAND, OH 44115-1234

Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio

VOID VOIDTRI-CITY CONSULTANTS

PO BOX 29123CLEVELAND, OH 44115-1234


Visit MedMutual.com

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Note: The layout of the form will be identical for Consumers Life and Carolina Care Plan, the only difference(s) being the individual logo and address.

Front

Section X


2

BackRETURN CHECK FORM

**Please use the form listed below when returning refunds**

Policy Holders Name: ________________________________ Patient Name: ____________________________ Date of Service: ________________

Claim or Check #: ________________________________ Certificate Nbr:____________________________ Amt of Refund: _________________

Reason for Refund: __________________________________________________________________________________________________________













********************ALWAYS SUPPLY CARRIER’S EXPLANATION OF BENEFITS (when applicable)********************

Send Refunds to the Appropriate Address Below:

Medical Mutual Carolina Care Plan Consumers LifePO Box 951244 PO Box 92250 PO Box 73522Cleveland, Ohio 44193 Cleveland, Ohio 44193 Cleveland, Ohio 44193

sample check voucher continued

Section X


3

sample Notice oF paymeNt (Nop) Form

0105

43.97

SUPERMED PLUSP. O.BOX 6018CLEVELAND, OH 441011-800-362-1278

PATIENT NAME: CARDHOLDER, JANE

TRI-CITY CONSULTANTSPO BOX 29123CLEVELAND, OH 44115-1234

NOTICE OF PAYMENT2060 East Ninth StreetCleveland, Ohio 44115-1355

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PATIENT BILLING NUMBER DATE OFSERVICE

PROCCODE

MED/OTHERINS PAID

PROVIDERCHARGES

*RMKCODE

*PT

*BC

ALLOWEDCHARGES

DEDUCTIBLE/COPAY

COINSURANCEAMOUNT

AMOUNTPAID

PATIENTLIABILITY

DATE03-21-2008PAYEE NUMBER860511234 - 002CHECK NUMBER5272123PAGE

1

CONTRACTUALWRITE-OFF

ID NUMBER: 123456551212 CLAIM NUMBER: 55121255510002-8428.234 11/07/2008 36415 8.00 U M E26 3.00 3.00 3.00 0.00 2-8428.234 11/07/2008 99214 85.00 U M E30 79.96 25.00 10.99 43.97 CLAIM TOTAL 93.00 82.96 28.00 10.99 3.00 43.97

TOTAL DAYS: 22 CARVE OUT DAYS: 0 NET DAYS: 22

TOTAL ACTIVITYDid you know, that for a quick response on a corrected claim we will accept the following over the phone: Diagnosis Code, CPT Code, Date of Service, Modifiers, Surgery Codes, On-Set Days and Workers Comp Information. Your office may contact the Call Center at 800/362-1279.

PLEASE SEE THE LAST PAGE FOR AN EXPLANATION OF CODES


Front

Note: Carolina Care Plan providers may contact the Call Center at 800/315-3143

Section X


4

Notice oF paymeNt

E26 THE AMOUNT IN THE “BENEFITS ALLOWED” COLUMN REPRESENTS MEDICARE’S ALLOWED AMOUNT FOR THIS SERVICE. YOU ARE RESPONSIBLE FOR MEDICARE’S ALLOWED AMOUNT MINUS THE SUM OF MEDICARE’S AND MMO’S PAYMENT. IF THE COMBINED PAYMENT BETWEEN MEDICARE (“PAID BY OTHER INSURANCE” COLUMN) AND MMO (“BENEFITS PAID” COLUMN) IS EQUAL TO MEDICARE’S ALLOWED AMOUNT (“BENEFITS ALLOWED” COLUMN) YOU HAVE NO FINANCIAL RESPONSIBILITY FOR THIS SERVICE.

E30 THIS CHARGE IS IN EXCESS OF MEDICARE’S ALLOWANCE FOR THIS SERVICES. BECAUSE THE PROVIDER ACCEPTS ASSIGNMENT FROM MEDICARE, THE PROVIDER WILL ACCEPT THE ALLOWED AMOUNT AS PAYMENT IN FULL. THE PATIENT IS RESPONSIBLE FOR ANY AMOUNTS LISTED AS DEDUCTIBLE OR COINSURANCE.

explanation of codes

pt (payment type)

U = Traditional

B = SuperMed

S = Schedule

O = Other

X = Primary Allowed

Remark Code

Bc (Benefit code)

B = Basic

M = Major Med

S = Supplemental Accident

C = Credit Reserve

The following codes refer to a specific narrative comment explaining why a charge or a portion of a charge was not allowed:

PROMPT PAYMENT REGULATIONS

TOTAL DAYS: The total number of days from claim receipt through paid date. If “exempt”, the claim does not apply to the regulation.

CARVE OUT DAYS: The total number of days exempt from interest calculations.

NET DAYS: The difference between total days less carve out days.

Interest for “X” DATE: The total number of days exempt from interest calculations.

Provider appeal process: If you do not agree with a claim decision, you or the patient has the right to appeal. Provider appeal requests, along with supporting information including medical recors, photos or x-rays, must be received within 180 days from the date of receipt of this notice. Submit a completed Provider Action Request (PAR) form along with supporting information to Provider Inquiry, P.O. Box 94917, Cleveland, OH 44101-4917, or fax: 216/687-2614

sample Notice oF paymeNt (Nop) Form continued

Back

Section X


5

* CPT only © 2009 American Medical Association. All Rights Reserved.

sample Notice oF paymeNt (Nop) Form continued

eXplaNatioN oF Nop iNFormatioNpatient Billing Number: Patient’s (history/account) number assigned by your

office from Item 26 of the CMS-1500 Claim Form, limited to the first 9 positions

Date of service: Date the service was incurred

proc code: 5 digit CPT* code

provider charges: Amount charged for the service incurred as it appears in Item 24F of the CMS-1500 Claim Form

pt: (Payment Type) U = Traditional B = SuperMed S = Schedule O = Other X = Primary Allowed

Bc: (Benefit Code) B = Basic M = Major Medical S = Supplemental Accident C = Credit Reserve

rmk code: Remark code refers to a specific narrative explaining why a charge or a portion of a charge was not allowed. The explanation of codes will appear on the last page(s) of the mailing.

allowed charges: Fee schedule in effect for this date of service, based on the patient’s policy or flat dollar copayment

Deductible: Amount of the charge that is applied towards the deductible, based on the patient’s policy

coinsurance amount: Percentage of the allowed charges after deductibles payable by the patient

med/other ins. paid: Amount paid by another insurance (i.e., Medicare, COB, Workers’ Compensation), when applicable

amount paid: Amount to be paid for the service incurred, based on the patient’s policy

patient liability: Amount owed by the patient after the allowed amount has been paid (i.e., deductible amount, copayments, or non-covered Services)

contractual Write-off: Difference between charges and contracted rate

Section X


6

sample aDJustmeNt summary Form

total aDJustmeNt BalaNce Due 399.24-

T82 A 16071X23465 MAN, JOHN A. 912345769 1334567981000 11/07/07 03/18/08 661.50- 661.50- 262.26 262.26 399.24- 355910009916

summary total 661.50- 661.50- 262.26 262.26 399.24-

ANESTHESIA CONSULTANTSPO BOX 12345DAYTON OH 45414-5123



ADJUSTMENT (TAKE BACK) SUMMARY

A = CURRENT OR PRIOR-PERIOD ADJUSTMENT.C = REFUND/RETURNED CHECK APPLIED AGAINST ADJUSTMENT BALANCE.D OR W = REMOVAL OF ADJUSTMENT AMOUNT.M = MANUAL ADJUSTMENT ACTIVITY.T = TRANSFER OF PRIOR ADJUSTMENT BALANCE TO ANOTHER PAYEE NUMBER.U = UPDATE/CHANGE TO ORIGINAL ADJUSTMENT BALANCE OR REFUND/RETURNED CHECK INFORMATION.

PLEASE KEEP THIS SUMMARY. IT MAY BE USEFUL WHEN YOU UPDATE YOUR PATIENT ACCOUNT RECORDS.c8206l 12/12/94

aDJcoDe

aDJtype

patieNtNumBer iD NumBer claim NumBer

Date oFservice

Date paiD

reFuNDreturNeDcheck No.

oriGiNalBalaNce

priorBalaNce

toDaysrecovereD

amouNt

total recovereD

amouNtDescriptioN

curreNtBalaNce

Due

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DATE03-20-2008PAYEE NUMBER861234567-002ACCOUNT ID01

PAGE1


Front

Section X


7

BackaDJustmeNt reasoN coDe leGeND

t82 aDDitioNal/late iNFormatioN/charGes suBmitteD

sample aDJustmeNt summary Form continued

Section X


8

eXplaNatioN oF aDJustmeNt (take Back) summary iNFormatioNadjustment code: This code is used to describe the reason why the

claim was adjusted.adjustment type: A – Current or prior – period adjustment C – Refund/returned check applied against adjustment balance D or W – Removal of adjustment amount M – Manual adjustment activity T – Transfer of prior adjustment balance to another payee number U – Update/change to original adjustment balance or refund/return check information

patient Number: Patient’s (history/account) number assigned by your office

Description: Last and first name of the patient or a description of the item that was adjusted

certificate Number: Patient’s ID number

claim Number: 13 digit number assigned

Date of service: Date the service was incurred

Date paid: Date on which the claim was adjusted as listed on the NOP

refund/returned Refund/returned check applied against the prior check No.: balance owed

original Balance: Original adjustment balance owed on this claim

prior Balance: Adjustment balance carried forward from current balance due (last column) on the previous adjustment summary

sample aDJustmeNt summary Form continued

today’s recovered A portion of the original balance reduced by today’s amount: claim payment activity (amounts paid on NOP), refund/returned checks or removal of adjustment amounttotal recovered The cumulative recovered amounts through todayamount:

current Balance Current balance is the original balance less the total Due medical mutual: recovered amount. This amount represents funds owed.

total adjustment The amount carried forward to the next adjustment Balance Due: summary under prior balance and which is listed as the adjustment amount owed as of the date of this adjustment summary, on the next activity summary

Section X


9

sample “No check” Formexplanations:

a Amount owed as of the last statement.

b Manual adjustment. Not reflected on the NOP.

c Amount owed after applying manual adjust-ment activity.

d See Total Activity amount on the lower right hand corner of the last page of the NOP.

e Funds returned by the provider for specific claims to clear an outstanding adjustment balance.

f This amount is carried from Item c above.

g Total Adjustment balance due.

Note: The layout of this form will be identical for Consumers Life and Carolina Care, the only difference(s) being the individual logo and address.

DATE: 03/20/2008PAYEE NUMBER: 861234567-002CHECK NUMBER: NO CK



ANESTHESIA CONSULTANTSPO BOX 12345DAYTON, OH 45414-5123

ADJUSTMENT BALANCE DUE

a ADJUSTMENT AMOUNT OWED AS OF 03/14/2008 0.00

b LESS MANUAL ADJUSTMENTS 0.00

c NET BALANCE OWED PRIOR TO APPLICATION OF TODAY’S ACTIVITY 0.00

d TOTAL PAYMENTS (SEE POSITIVE AMOUNTS PAID ON NOTICE OF PAYMENT) 0.00

LESS TODAY’S ADJUSTMENTS (SEE NEGATIVE AMOUNTS PAID ON NOTICE OF PAYMENT) 112.95-

112.95-

e PLUS FUNDS RETURNED TO CLEAR ADJUSTMENT BALANCE(S) 0.00

f LESS NET BALANCE OWED PRIOR TO APPLICATION OF TODAY’S ACTIVITY 0.00

g CURRENT ADJUSTMENT BALANCE OWED 112.95-

activity summary

CB209P 9/94

08

Section X


10

sample proviDer iNvoice

it is importaNt to have your paymeNt processeD By the Due Date to avoiD haviNG Future paymeNts reDuceD By this outstaNDiNG BalaNce

FAMILY MEDICAL CENTERPO BOX 44997CLEVELAND, OH 44115-1022



INVOICE NUMBER: 6074-00119

INVOICE DATE: MAR 15, 2008

MAR 15, 2008

112233445-002

MAR 1, 2008

113.33

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www.medmutual.com


proviDer NumBerFor the perioD throuGh

total aDJustmeNts For this perioD - BalaNce Due $ (SEE THE ATTACHED STATEMENTS FOR DETAIL)

cB201p 7/29/02

mail this portion with your payment

iNvoice NumBer 6074-00119

proviDer NumBer: 112233445-002

Due Date: april 19, 2008

BalaNce Due: 113.33

amouNt paiD $___________

Note: Do Not mail cash

please seND check to:

p.o. BoX 951248clevelaND, oh 44193-0011


Front

Section X


11

Back

provider action requestsFor questions regarding this invoice, please contact the Provider Inquiry Unit using the phone number listed on the accompanying statements within 30 days. If you do not agree with a claim decision, you or the patient has the right to appeal. Provider appeal requests, along with supporting information including medical reports, photos or x-rays, must be received within 180 days from the date of receipt of this notice. Submit a completed Provider Action Request (PAR) form along with supporting information to: Provider Inquiry, P.O. Box 94917, Cleveland, OH 44101-4917, or fax: 216/687-2614.

sample proviDer iNvoice continued

Section X


12

sample Notice oF paymeNt iNvoice statemeNt

0105

113.33 -

SUPERMED PLUSP. O.BOX 6018CLEVELAND, OH 441011-800-362-1278

PATIENT NAME: CARDHOLDER, JANE


NOTICE OF PAYMENT2060 East Ninth StreetCleveland, Ohio 44115-1355

Visit MedMutual.com


PATIENT BILLING NUMBER DATE OFSERVICE

PROCCODE

MED/OTHERINS PAID

PROVIDERCHARGES

*RMKCODE

*PT

*BC

ALLOWEDCHARGES

DEDUCTIBLECOINSURANCE

AMOUNTAMOUNT

PAIDPATIENT

LIABILITY

DATE03-15-2008PAYEE NUMBER112233445 - 002INVOICE NUMBER6074-00119PAGE

1

CONTRACTUALWRITE-OFF

*ID NUMBER: 123456551212 *PRIOR ID NUMBER: 234565789 CLAIM NUMBER: 60242032840002-8428.234 11/11/2008 92083 90.00- M E23 76.21- 66.21- 10.00- 2-8428.234 11/11/2008 99215 120.00- M E23 113.33- 10.00- 103.33- CLAIM TOTAL 113.33-

TOTAL ACTIVITY

Did you know, that for a quick response on a corrected claim we will accept the following over the phone: Diagnosis Code, CPT Code, Date of Service, Modifiers, Surgery Codes, On-Set Days and Workers Comp Information. Your office may contact the Call Center at 800/362-1279.

PLEASE SEE THE LAST PAGE FOR AN EXPLANATION OF CODES

INVOICE STATEMENT

2-8428.234 11/11/2008 92083 90.00 V02 0.00 0.00 0.00 90.00 2-8428.234 11/11/2008 99215 120.00 V02 0.00 0.00 0.00 120.00 CLAIM TOTAL 0.00

PREVIOUSLY PAID BY CHECK #2222333 ON 02/-15-2008ADJUSTMENT REASON: DUPLICATE PAID CLAIM AMOUNT OWED 113.33-

PATIENT NAME: CARDHOLDER, JANE *ID NUMBER: 123456551212 *PRIOR ID NUMBER: 234565789 CLAIM NUMBER: 6024203284000


Front

Section X


13

sample Notice oF paymeNt iNvoice statemeNt continued

BackNotice oF paymeNt

E23 THE PROVIDER PARTICIPATES IN THE NETWORK PROGRAM. THE ALLOWED AMOUNT IS THE LESSER OF THE NETWORK FEE OR THE ACTUAL CHARGE FOR THIS SERVICE. THE PROVIDER HAS AGREED TO ACCEPT THIS AS PAYMENT IN FULL. THE PATIENT ONLY IS RESPONSIBLE FOR ANY DEDUCTIBLE AND/OR COINSURANCE AMOUNTS.

V02 THIS CHARGE IS A DUPLICATE OF A CLAIM THAT HAS BEEN PREVIOUSLY PROCESSED

explanation of codes

pt (payment type)

U = Traditional

B = SuperMed

S = Schedule

O = Other

X = Primary Allowed

Remark Code

Bc (Benefit code)

B = Basic

M = Major Med

S = Supplemental Accident

C = Credit Reserve

The following codes refer to a specific narrative comment explaining why a charge or a portion of a charge was not allowed:

PROMPT PAYMENT REGULATIONS

TOTAL DAYS: The total number of days from claim receipt through paid date. If “exempt”, the claim does not apply to the regulation.

CARVE OUT DAYS: The total number of days exempt from interest calculations.

NET DAYS: The difference between total days less carve out days.

Interest for “X” DATE: The total number of days exempt from interest calculations.

Provider appeal process: If you do not agree with a claim decision, you or the patient has the right to appeal. Provider appeal requests, along with supporting information including medical records, photos or x-rays, must be received within 180 days from the date of receipt of this notice. Submit a completed Provider Action Request (PAR) form along with supporting information to Provider Inquiry, P.O. Box 94917, Cleveland, OH 44101-4917, or fax: 216/687-2614

sample check voucher - laduainc.comladuainc.com/pdf/mmo_09/providermanual/notice_of_payment.pdf ·...

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