Admit – Date of admission recorded by your agency for the episode. Use this field to recognize different admissions for the same patient.
Admits – Number of admission RAPs for the month. Use this information to compare MAC records and internal records. The actual number of PPS admissions performed during the month and the Admits reported here should be approximately the same.
ADR – Additional Documentation Request
Code submitted with the claim by your agency so the MAC can process the claim. The 34x report does not use these bill types.
For episode claims, the following bill types may appear:
|
Code |
Description |
|
320 / 330 |
RAPs/EOE claims with a status of T, Rejected, or Denied |
|
322 / 332 |
RAP |
|
329 / 339 |
EOE |
|
328 / 338 |
RAP/EOE cancellations |
|
32G / 33G |
Adjustments imposed by the MAC |
|
3x7 |
Adjustments submitted by the provider |
|
340 |
Non-episode outpatient claims |
|
341 |
Non-episode outpatient claims with a status of Terminated, Rejected, or Denied |
For hospice claims, the following bill types may appear:
|
Code |
Description |
|
81A |
Election / Admission Notice (Notice of Election) |
|
81B |
Termination / Revocation |
|
81C |
Change (Transfers) / Change of Provider |
|
81D |
Void |
|
81E |
Change in Ownership |
|
811 |
Admit Through Discharge Claim |
|
812 |
Interim – First Claim |
|
813 |
Interim – Continuing Claim |
|
814 |
Interim – Last Claim |
|
815 |
Late Charge Only |
|
817 |
Replacement (Adjustment) of Prior Claim |
|
818 |
Void / Cancel of a Prior Claim |
Billing Status Date – Date the billing status of the claim was determined by the MAC.
Calculated Cert End – Date the episode is expected to end, assuming the patient has not been discharged.
Cancelled – Date the claim was cancelled. For episode claims in general, if a RAP is cancelled because the corresponding EOE has been paid, this date matches the Paid field. This does not occur in the All Episodes and 34x reports in the All file.
Cancelled EOEs – Number of EOEs that were cancelled by either your agency or the MAC.
Cancelled Episodes – Number of episodes which were cancelled by either your agency or the MAC.
Cancelled RAPs – Number of RAPs that were cancelled by a non-EOE claim. Use this field to monitor the number of RAPs that may have been cancelled due to EOE submission delays.
Canceller Bill Type – Bill type of the claim that cancelled the original claim: 328 / 338 – RAP/EOE cancellations.
Canceller Paid Date – Date the claim that cancelled the original claim was paid.
Canceller Received Date – Date the claim that cancelled the reported claim was processed.
Canceller Status – Status of the claim that cancelled the original claim.
Cap Election Period – Hospice cap election period as indicated on the claim. Use this information to see and sort by the hospice cap election period.
CBSA – Core Based Statistical Area (CBSA) code indicated on the claim.
Cert / Cert Date – First day of the episode.
Cert Month – Month in which the reported episodes began.
Charge – Charge reported with the claim. It is not considered when determining payment for episode and hospice claims. For RAPs, this field is generally zero. For EOEs, it is generally the amount that would have been charged under fee-for-service. This does not occur in the HEALTHCAREfirst RA, All Episodes, and 34x reports.
Claim Age – Number of days since the claim was received by the MAC.
Claim Count – Number of claims paid on the current date.
Claim Type / Type – Common name for bill type, such as RAP, EOE, RAP/Can, or EOE/Can. Unknown types of claims are marked with a dash (-). To determine if a claim is a RAP or EOE, look at the From and Thru fields on the report.
Claims – Number of claims which fall into the indicated episode status category.
Current Status – See Status.
Date RAP Will Be Cancelled – Date the MAC will cancel the RAP if the EOE has not been submitted. Use this field to obtain the deadline for submitting the EOE.
Days – Number of days into the episode that the claim was submitted. The first day of the episode is day one.
Days Since Episode Ended – Number of days since the end of the episode, based on a 60-day episode. Use this field to indicate how long each EOE submission has been delayed.
Days Until RAP is Cancelled – Number of days until the corresponding RAP will be cancelled if the EOE is not received. Use this field to prioritize the development of EOEs for submission.
EOE – Episode-final
Payment or billing status of the EOE claim:
● Due – Episodes for which the RAP will be cancelled if the EOE is not submitted within 60 days. The episode has ended and an EOE is due. This status is determined by HEALTHCAREfirst and the EOE claim will not have a corresponding record with the MAC.
● Suspense – EOEs that have a status of Suspense. The final claim for the episode was recently submitted.
● Terminated (T) – EOEs that have a status of T. This row excludes T/ADR claims. This row also excludes claims which were replaced by another claim.
● Rejected – EOEs that have been rejected. This row excludes claims which were replaced by another claim.
● Cancelled – Episodes for which payment is being withheld because the EOE has been cancelled.
EOE Submission Delay – Average delay between the end of episode and the EOE received date.
Episode – Number of the episodes for this admission. If the patient is discharged and re-admitted at a later date, the count restarts.
Episode Master – An automated QA tool that finds inconsistencies in data to locate potential errors before submission.
Billing status of the episode. Use this field to determine why the claim was not paid and if the determination can be appealed. See also Status page 37 . The Episode Status is determined by HEALTHCAREfirst and may not necessarily correspond to a single MAC status:
● Denied – Episodes with at least one claim that has been denied payment.
● Replaced – Episodes that have been replaced by creating another episode with slightly adjusted dates. An episode is considered replaced when it shares at least 30 days with another paid episode.
● Ineligible – Episodes which are ineligible for Medicare payments. Episodes with one or more claims that have a status of Suspense or Denied are excluded. Episodes are ineligible if they meet any of the following criteria:
The reason code for any claim in the episode contains any of the following phrases:
● Primary payer
● HMO period
● HIQA
● Not on file
● Date of death
● Is not entitled
● Overlapping a hospice
● Positive working elderly
● Primary over Medicare
● Positive disability record
● Positive auto/liability record
● The claim should be billed to
There are no paid claims in the episode, and the reason code for any claim in the episode contains one of the following phrases: “duplicate” “OVERLAP”
For HMO Watch clients, an HMO enrollment period is detected that overlaps the episode.
ADR – Additional Documentation Request. The MAC will not process the claim until it receives more information from the provider. Refer to the reason code associated with the claim for additional information. ADRs that are not addressed may be terminated by the MAC.
Estimated EOE Value – The expected net reimbursement for EOE claims.
Estimated Episode Value – The expected net reimbursement for an episode. The estimated value is the full value of the episode. This field does not attempt to calculate partial payments. The Estimated Episode Value for episodes that have been replaced with another paid episode is always $0.
Estimated RAP Value – The expected net reimbursement for RAPs.
Expected EOE Payment – Payment amount assigned to the EOE by the MAC.
From / Thru – First and last day covered by the claim. In episode claims, RAPs have the same date for From and Thru.
HIC – The Medicare Health Insurance Claim number is a patient’s unique identification code on his or her Medicare card. HIC number will appear in the claim.
Internal Patient Number – Number assigned within your agency to identify patients. Use this number for patient tracking and to separate patients for your different branches or offices. For example, the code may include GRN if a patient is admitted to an office on Green Street.
Legacy Reports – Formerly Lewis FSD reports. All Legacy reports will be in Microsoft Excel format and will have to be downloaded from the BI portal.
Code in STLLLL format that identifies the location of the claim within the MACs system. Use this field to identify problems with the claim’s submission.
● S – Status; Suspense (S), Paid (P), Terminated (T), Rejected (R), Denied (D), Inactive (I)
● T – Type; Batch (B), Manual (M)
● L – Location
If the location is TB9900, the status is T, it was submitted in a batch, and the location is 9900.
MAC – Medicare Administrative Contractor
Net Reimb – Actual payment your agency will receive. It is determined by claim type and status. When cancelled episode claims are paid, Net Reimb shows the reduced amount. For EOE claims in general, the Net Reimb is equal to the claim’s Reimb less the Net Reimb of the corresponding RAP (EOE Net Reimb = EOE Reimb – RAP Net Reimb). This may not occur in the All Episodes and 34x reports, depending on the type of claim.
NOE – Notice of Election
NPI – Provider Number
Indicator that the claim is no longer valid for one of these reasons:
● This unpaid claim was replaced by a new claim.
● This paid claim was already billed.
● This paid claim was cancelled by you or your MAC.
Use this field to identify active unpaid claims that may represent lost revenue. Investigate obsolete, unpaid claims to improve your billing procedures.
Paid – Date the claim was paid or the claim’s status was changed to T, Rejected, or Denied, as determined by the report. In the RAP History and RAP History All reports, for claims submitted before the Receivables Intelligence reporting period, this is the date as reported by the MAC when it first appears on the reports.
Paid EOEs – Number of EOEs that have been paid for the month.
Paid RAPs – Number of RAPs that have been paid for the month.
Patient Name – Patient name appearing in the claim.
Physician – Practitioner indicated on the RAP. Use this information to find out which practitioners must sign orders so the EOE can be submitted.
PPS – Prospective Payment System
Previous Cert Start – SOE date of the previous episode.
Previous Cert Stop – EOE date of the previous episode.
Previous Patient Status – Patient status from the previous EOE claim.
Previous Status – Previous status for a claim that has changed since your last update
Pt – Patient name and HIC number.
Pt Status – Patient status as indicated on the claim. Use this information in episode and hospice claims to see and sort by the final patient status, such as Discharged or Expired.
RA – Remittance Advice
RAP – Request for Anticipated Payment
RAP Delay – Number of days since the expected start of an episode, according to the EOE from the previous episode.
RAP Paid Date – Date the RAP was scheduled for payment.
RAP Payment – Payment amount assigned to the RAP by the MAC.
Payment status of the RAP:
● Suspense (S) – Holding status for all incoming RAPs. This is the first stage of a normal episode.
● Terminated (T) – RAPs which have a status of T. This row excludes T/ADR claims. This row also excludes claims which were replaced by another claim.
● Rejected (R) – RAPs which have been rejected. This row excludes claims which were replaced by another claim.
● Cancelled (C) – Episodes for which payment is being withheld because the EOE has been cancelled.
RAP Submission Delay – Average delay between the start of episode and the RAP received date.
Internal code within the MAC that indicates the reason for the claim's status. A description of each reason code can be viewed by hover your pointer over the code. Contact your MAC for a complete list of reason codes.
Disclaimer: HEALTHCAREfirst updates the reason codes directly from the MAC twice a month. Because Medicare changes these codes regularly, please verify them with Medicare before making any billing determinations.
Received – Date the MAC recorded receiving the claim. In the applicable reports, this includes claims generated by the MAC, such as RAP cancellations. If a terminated claim is corrected online, the date changes to the date the claim was corrected.
Recerts – Number of recertification RAPs for the month.Use this information to compare MAC records and internal records. The actual number of PPS recertifications performed during the month and the Recerts reported should be approximately the same.
Reimb – Reimbursement amount assigned to the claim by the MAC.
Replaced – Indicates an episode that has been replaced by another paid episode. The paid episode must overlap the replaced episode by at least 30 days. This typically indicates a problem that has already been corrected.
SOE – Start of Episode
Payment status of the claim. This is the status assigned to the claim by the MAC.
A claim’s status may be one of the following:
● Suspense (S) – Holding status for all incoming claims. This is the first status assigned to a normal claim.
● Suspense (S)/ADR – Suspense claim for which the Reason Code indicates an ADR.
● Paid (P) – Claim accepted and scheduled for payment.
● Terminated (T) – Claim that will not be paid in its current form. You can either correct this claim online or resubmit another claim in its place. If the claim is corrected online, it will return to Suspense status.
● Terminated (T)/ADR – Terminated claim for which the Reason Code indicates an ADR.
● Rejected (R) – Claim that will not be paid. You may be able to submit another claim in its place.
● Denied (D) – Claim that will not be paid. You cannot submit another claim in its place.
● Inactive (I) – Claim submitted by the MAC as a correction or cancellation of another claim.
For the RAP History and RAP History All reports, this is the status of the claim when it was received by the MAC. For claims submitted before the Receivables Intelligence reporting period, it is the status of the claim when it first appears on the reports. Use this field to identify what is required to get the claim paid.
T – Terminated, A claim status.
Thru – See From / Thru.
Today’s Additions – Number of claims which were placed into the respective category for billing status.
Total EOEs – Total number of EOEs for the month.
Total Episodes – Total number of episodes submitted under your agency NPI.
Total RAPs – Total number of RAPs for the month. Use this field to compare intermediary records and internal records. The Total RAPs here should match the number of RAP claim reported by your billing application.
Type – See Claim Type.
Unpaid EOEs – Number of EOEs that have been submitted but not paid for the month. Cancelled EOEs are not included.
Unpaid RAPs – Number of RAPs that have been submitted but not paid for the month. Cancelled RAPs are not included.