POS NOS MIC PROS MODS PERE PORY SERV DATE NAME: DOL, JOHN 0921 092119 BILLED ACCT:653457 COINS ALLOWED DEDUCT ION 52.59 0.00 11 99313 B000 GRP/RCAMY PROVPD ASOY MOA MAOL MAIS 17.41 49.07 1.00 1141 4907 12.5200-45 CO-253 12.52 PT RESP: 2912 CLAIM TOTALS CLAIM INFORMATION FORWARDED TO: GROUP HEALTH COOPERATIVE 30.00 6259 0.00 NAME: SMITH, SUSAN 0921 092119 HIC 11 99213 25 ACCT: 452678 80.00 ION 62.59 0.00 NET 19.07 ASG Y MOA MADI MAIN 1741 19.07 100 123 00 0.00 12.52 C0-45 CO-253 0.00 CO-815 0921 092119 11301 123.00 0.00 0.00 0921 092119 11 17000 74.00 5738 000 4498 0921 092119 17000 14.00 966 0.00 1148 CO-45 Co-253 193 C0-45 00-253 2593 16.62 092 434 0.15 163 44 758 PT RESP: 2593 CLAIM TOTALS CLAIM INFORMATION FORWARDED TO: PREMERA FEP/EASTERN WA 291 00 129 63 0.00 10163 TOTAL CLAIMS MET BULD ALLOWED 37100 DEDUCT AMT 000 COINS AMT 3845 PROVPD AMT 150.70 101.63 CHECK AMT 150 70 2 GLOSSARY: Group, Reason, MOA, Remark and Adjustment Codes CO Contractual obligation. Amount for which the provider is financially liable. The patient may not be billed. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. 253 Sequestration - reduction in federal payment MAO1 Alert: If you do not agree with what we approved for these services, you may appeal our decision. MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. QUESTIONS: (Please number your answers) CLAIM FOR JOHN DOE 1. Explain why the provider must the provider adjust $17.41? 2. Explain why the provider must the provider adjust $1.00? 3. What does remittance advice remark code MA18 mean? 4. If the provider did not agree with the payment from Medicare on John Doe's claim, can they appeal? If so, what are the guidelines for appealing? (You learned about filing an appeal in the CMS assignment) Edit View Insert Format Tools Table 12pt Paragraph I o , POS NOS MIC PROS MODS PERE PORY SERV DATE NAME: DOL, JOHN 0921 092119 BILLED ACCT:653457 COINS ALLOWED DEDUCT ION 52.59 0.00 11 99313 B000 GRP/RCAMY PROVPD ASOY MOA MAOL MAIS 17.41 49.07 1.00 1141 4907 12.5200-45 CO-253 12.52 PT RESP: 2912 CLAIM TOTALS CLAIM INFORMATION FORWARDED TO: GROUP HEALTH COOPERATIVE 30.00 6259 0.00 NAME: SMITH, SUSAN 0921 092119 HIC 11 99213 25 ACCT: 452678 80.00 ION 62.59 0.00 NET 19.07 ASG Y MOA MADI MAIN 1741 19.07 100 123 00 0.00 12.52 C0-45 CO-253 0.00 CO-815 0921 092119 11301 123.00 0.00 0.00 0921 092119 11 17000 74.00 5738 000 4498 0921 092119 17000 14.00 966 0.00 1148 CO-45 Co-253 193 C0-45 00-253 2593 16.62 092 434 0.15 163 44 758 PT RESP: 2593 CLAIM TOTALS CLAIM INFORMATION FORWARDED TO: PREMERA FEP/EASTERN WA 291 00 129 63 0.00 10163 TOTAL CLAIMS MET BULD ALLOWED 37100 DEDUCT AMT 000 COINS AMT 3845 PROVPD AMT 150.70 101.63 CHECK AMT 150 70 2 GLOSSARY: Group, Reason, MOA, Remark and Adjustment Codes CO Contractual obligation. Amount for which the provider is financially liable. The patient may not be billed. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. 253 Sequestration - reduction in federal payment MAO1 Alert: If you do not agree with what we approved for these services, you may appeal our decision. MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. QUESTIONS: (Please number your answers) CLAIM FOR JOHN DOE 1. Explain why the provider must the provider adjust $17.41? 2. Explain why the provider must the provider adjust $1.00? 3. What does remittance advice remark code MA18 mean? 4. If the provider did not agree with the payment from Medicare on John Doe's claim, can they appeal? If so, what are the guidelines for appealing? (You learned about filing an appeal in the CMS assignment) Edit View Insert Format Tools Table 12pt Paragraph I o
