| Field Name |
Field Description |
| Billing Provider ID |
Billing provider Medicaid specific ID. |
| Billing Provider NPI |
Billing provider National Provider Identification Number. |
| Name |
Name of Billing Provider. |
| Pay Cycle |
Pay cycle for the Remittance Advice according to the Remittance Advice Schedule. |
| RA Number |
Remittance Advice Identification Number |
| RA Date |
Date the Remittance Advice was created. |
| Financial Adjustments |
Shows financial adjustments for the Remittance Advice. |
| Adjustment Type |
Type of adjustment applied to the claim. |
| Previous Balance |
Previous balance for the provider. |
| Adjustment Amount |
Provider adjustment amount (+ or -). |
| Remaining Balance |
Provider remaining balance after adjustments to claims are applied to the Remittance Advice. |
| Checks Received |
Checks received by the provider to satisfy a credit balance |
| Count |
Count of checks received from the provider. |
| Amount |
Total check amount of all checks received for credit balance |
| Claims Summary |
Claims summary count. |
| Status |
Status of claims : Paid/Credited /Denied/Gross Adjustment |
| Count |
Count for each claim status. |
| Total Billed Amount |
Total billed amount for each claim status. |
| Total Approved Amount |
Total approved amount for each claim status. |
| Paid |
Number of Paid claims. |
| Credited |
Number of Credited claims. |
| Denied |
Number of Denied claims. |
| Gross Adjustment |
Number of Gross Adjustments. |
| Payment Summary |
Shows Provider payment summary. |
| Total Payment Approved Amount |
Total Claims payment amount including any checks applied. This includes all paid claims from and claim status |
| Balance Owed Deduction |
Previous Balance deducted up to the total payment amount. |
| Warrant/EFT Amount |
Total Medicaid EFT paid amount. |
| Warrant/EFT # |
Warrant or Electronic Fund Transfer number. |
| Warrant/EFT Date |
Warrant or Electronic Fund Transfer date. |
| Beneficiary Name/Beneficiary ID/Patient Account #/Gross Adj ID |
Beneficiary Name/Beneficiary ID/Patient Account #/Gross Adj ID. |
| TCN/ Original TCN/Recovery Check # |
All TCN (claim) numbers that apply to the Remittance Advice |
| Rendering Provider ID/NPI/Name |
Rendering provider information including Provider ID, NPI and Name |
| Invoice Date/Service Date(s) |
Invoice Date (for Gross Adjustments), Service Dates. |
| Revenue/Procedure/Modifier |
Revenue Code(s), Procedure Code(s), and Modifier(s) as applicable. |
| PPS/DRG/APC |
PPS (Perspective Payment System); DRG (Diagnosis Related Grouping) - For Inpatient; APC (Ambulatory Payment Classification) - For Outpatient. For institutional claims only. |
| Qty |
Amount of unit’s billed |
| Billed Amount |
The billed amount on the claim. The service line reports the individual billed amount from each line. |
| Approved Amount/Check Applied Amount |
Approved Amount on the claim. The service line reports the line approved amount. Credited claim status shows the total amount reversed (credited) from the original claim. Check applied amount for recovered claims. |
| TPL and Medicare Amount |
TPL/Other Payer Insurance Amount – This is the total the primary insurance paid |
| Member Responsible Amount |
Indicative of co-pay for plans that require this be paid for select plans. |
| PPA |
Patient Pay Amount (Patient Contribution). Applied to Nursing Home claims. Also, can be identified as RL (Resident Liability) or SOC (Share of Cost) |
| Error Code |
This is indicating denied or pay and report Medicaid specific codes. |
| Status Totals |
The total status amounts included on the Remittance Advice including claims, TPL, member responsibility, PPA and each claim status. |
| Claim Adjustment Reason Codes (CARC) Details |
Claim Adjustment Reason Codes Details. |
| Remittance Advice Remark Codes (RARC) Details |
Remittance Advice Remark Codes Details. |
| Error Code Details |
Medicaid specific error code details with associated CARC and RARC |
| Error Description |
Medicaid error code description. |
