Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER AFC-8 January 2002
TO:      Adult Foster Care Providers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      Adult Foster Care Manual (Revised Billing Instructions)
The letter transmits updates to the billing instructions (Subchapter 5) of the Adult Foster Care Manual to accommodate the new rate structure, as described in Adult Foster Care Transmittal Letter AFC-7.
If you have any questions about these billing instructions, contact the MassHealth Provider Services Department as 671-628-4141 or 1-800-325-5231,
These revisions are effective for dates of service on or after October 1, 2001.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Adult Foster Care Manual
Pages 5.3-1 through 5.3-8 and 5.5-1 through 5.5-12.
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Adult Foster Care Manual
Pages 5.3-1 through 5.3-8 and 5.5-1 through 5.5-18 transmitted by Transmittal Letter AFC-4.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-1	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Part 3. How to Submit Claims
All adult foster care providers must use claim form no. 9 to bill MassHealth for services. Providers can request supplies of claim form no. 9 from the appropriate address or fax number listed in Appendix A of this manual. This section explains how to complete this claim form.
Electronic Claims
Electronic billing offers an effective and convenient alternative to paper billing. For information on submitting electronic claims on tape, diskette, or in other electronic formats, contact Electronic Claims Services at the address or telephone number listed in Appendix A of this manual.
Entering Information on Claim Form No. 9
 •	Complete a separate claim form, or follow the applicable electronic media claim format, for each member for whom services were provided.
 •	Type or print all required information on the claim form with black ink, using high quality printer ribbons or cartridges. Be sure all entries are complete, accurate, legible, and within the respective claim boxes.
 •	Do not italicize, bold, or underline characters.
 •	Do not enter negative amounts into any boxes.
 •	For each claim line, enter all required information, repeating if necessary. Do not use ditto marks or words such as “same as above.”
 •	Attach any necessary reports or required forms to the claim form, but be careful not to staple in the bar code printed in the upper-left portion of the claim form.
 •	When the required entry is a date (such as the date of service or the member's date of birth), enter the date in month/day/year order.
Example: For a member born on October 8, 1960, the entry in Item 11 should be as follows.

10	08	60	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-2	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Time Limitations on the Submission of Claims
The period established by state law for the submission of claims is 90 days. For regulations governing time limitations on the submission of claims, see the provider regulations in Subchapter 3 of this manual.
The 90-day period is measured from the date of service to the date on which the claim is received. Since the 90-day billing deadline applies to each claim line, the claim must be received within 90 days from the earliest date of service on the claim. When a claim line contains consecutive dates of service, the 90-day period is measured from the last date in the range (the date entered in the column labeled “To” in Item 26 of claim form no. 9).
All services listed on a single claim line must have been provided in the same fiscal year. That is, dates of service in the months of June and July should not appear on the same claim line.
Claims for Members with Other Health Insurance Coverage
Instructions for submitting claims for services provided to members with other health insurance coverage are located in Part 8 of these billing instructions.
Further Assistance
If, after reviewing the item-by-item instructions in the following section, you need additional assistance, contact MassHealth Provider Services. See Appendix A in this manual for the appropriate address and telephone numbers.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-3	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Instructions for Completing Claim Form No. 9
This section contains specific instructions for completing each item on claim form no. 9. Examples of properly completed claim forms for specific billing situations begin on page 5.3-8.

Item 1      PROVIDER'S NAME, ADDRESS & TELEPHONE NO.
Item 2       PAY TO PROVIDER NO.
Item 3	BILLING AGENT NO.
Item 4	PRIOR AUTHORIZATION NO.
Item 5	SERVICING PROVIDER'S NAME
Item 6	SERVICING PROVIDER NO.
Item 7	REFERRING PROVIDER'S NAME
Item 8	REFERRING PROVIDER NO.
Item 9	MEMBER'S NAME
Item 10	RECIPIENT ID NO.

Enter the provider's name, address, and telephone number.
Enter the provider’s seven-digit MassHealth number.
If this form is prepared by a billing agent, enter the seven-digit number assigned to the agent, if one was assigned. Otherwise, leave this item blank.
Leave this item blank.
Leave this item blank.
Leave this item blank.
For members enrolled with a PCC, enter the name of the member’s PCC.
For all other members, leave this item blank.
For members enrolled with a PCC, enter the PCC's seven-digit referral number.
For all other members, leave this item blank.
Enter the member’s name.
Enter the complete 10-character member identification (ID) number that is printed on the MassHealth card below or beside the member’s name. These characters may be all numbers or a combination of numbers and letters.

The member ID on the temporary MassHealth card may include an asterisk as the 10th character.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-4	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Instructions for Completing Claim Form No. 9

Item 11	DATE OF BIRTH
Item 12	SEX
Item 13	OTHER INSUR.
Item 14	PATIENT ACCOUNT NO.
Item 15     PLACE OF SERVICE
Item 16A IS MEMBER BEING TREATED AS A RESULT OF AN ACCIDENT?
Item 16B IF YES, TYPE &
Item 16C DATE OF ACCIDENT
Item 17     IS MEMBER BEING TREATED AS A RESULT OF EPSDT SCREENING?

Enter the member’s date of birth in month/day/year order.
Enter either an M for male or an F for female.
If the member is covered by other health insurance, enter an X.
Enter the patient account number or member’s last name (no more than 10 characters).
This patient account number or name will be printed on the remittance advice to help identify the claim.
Enter the code from the list below that describes the place in which the service was provided.
 01	- Office, facility, or business location
 02	- Member's home
 03	- Hospital, inpatient
 04	- Hospital, outpatient
 05	- Emergency department
 06	- Nursing facility
 07	- Rest home 99 - Other location
If the service was necessary because the member was involved in an accident, enter an X in the box labeled “Yes” and complete Items 16B and 16C. If the service was not accident-related or if the information is not available, enter an X in the box labeled “No” and leave Items 16B and 16C blank.
If the Yes box is checked in Item 16A, enter the code from the list below that describes the type of accident.
 1	- Automobile related
 2	- Employment related
 3	- Other
If the Yes box is checked in Item 16A, enter the date of the accident in month/day/year order.
Leave this item blank.

Item 18    L.O.F.

Leave this item blank.

Item 19     PATIENT STATUS

Leave this item blank.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-5	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Instructions for Completing Claim Form No. 9

Item 20	DISCHARGE DATE	
Item 21	DIAGNOSIS CODE	
Item 22	DIAGNOSIS NAME	
Item 23	DIAGNOSIS CODE	
Item 24	DIAGNOSIS NAME	
Item 25	LINE	
Item 26     DATES OF SERVICE
Item 27	DESCRIPTION OF SERVICE
Item 28	PROCEDURE CODE-MODIFIER
Item 29	TREAT. REL. TO DIAG.
Item 30	TREAT. REL. TO FAM. PL.
Item 31	UNITS OF SERVICE
Item 32	USUAL FEE

Leave this item blank.
Leave this item blank
Leave this item blank
Leave this item blank
Leave this item blank
Each letter (A through J) refers to one of the 10 claim lines contained on the claim form. This letter will appear as the last character of the claim's transaction control number (TCN) listed on the remittance advice.
For single dates of service, in the From column, enter, in month/day/year order, the date the service was provided. Leave the To column blank. Use a separate claim line for each date of service, except for consecutive dates.
For consecutive dates of service, enter the first date of service in the From column and the last date of service in the To column. Indicate the number of days billed during this span of dates in Item 31.
No entry is required. To complete this item for your records, enter a brief description of the service provided.
Enter the service code that corresponds to the service provided. Obtain the service code from Subchapter 6 of this manual.
Leave this item blank.
Leave this item blank.
Enter the number of days or units billed.
Enter the usual and customary fee (the amount you charge a person who is not a MassHealth member) for each service provided.
When billing for more than one unit, multiply the number of units in Item 31 by the usual and customary fee. Enter that product as the usual and customary fee.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-6	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Instructions for Completing Claim Form No. 9

Item 33     OTHER PAID AMOUNT
Item 34	EMERG. SERV.
Item 35	REMARKS
Item 36	TOTAL USUAL FEE
Item 37	TOTAL OTHER PAID AMOUNT
Item 38	AUTHORIZED SIGNATURE
Item 39     BILLING DATE
Item 40    ADJUSTMENT/RESUBMITTAL

Enter any amount received for the service from a source other than MassHealth, and attach to the claim form a copy of the notice of final disposition from the other payment source. Do not enter any previous payment received from MassHealth.
See Part 8 of these billing instructions for submitting claims for services provided to members with other health insurance coverage.
Any amount entered in Item 33 will be deducted from the MassHealth payment.
Leave this item blank.
Leave this item blank.
No entry is required. To complete this item for your records, calculate and enter the sum of the amounts entered in Item 32 (“Usual Fee”).
No entry is required. To complete this item for your records, calculate and enter the sum of the amounts entered in Item 33 (“Other Paid Amount”).
The form must be signed by the provider or by the individual designated by the provider to certify that the information entered on the form is correct. Signatures other than handwritten signatures (for example, stamped, typewritten, or computer-generated) are also acceptable.
Enter in month/day/year order the date on which the claim form is completed. The billing date may not precede any of the dates of service entered on the claim form.
Enter an X in the Adjustment or Resubmittal box only when an entry is required by the instructions for correcting a claim. See the section on correcting claims elsewhere in these billing instructions. Do not make any entry in this item without completing Item 41.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-7	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Instructions for Completing Claim Form No. 9
Item 41    FORMER TRANSACTION CONTROL       When an entry is required in this item, enter the
NO.	10-digit transaction control number (TCN) assigned
to the original claim. The TCN appears on the remittance advice that listed the original claim as paid or denied.
When resubmitting or adjusting a claim, include all attachments that were required for the original claim.

Item 42     FOR OFFICE USE ONLY

Leave this item blank.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-8	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Completed Claim Forms
This section contains examples of completed claim forms for the billing situations described below. For assistance with a billing situation not explained in these examples, contact MassHealth Provider Services at the appropriate address or telephone numbers listed in Appendix A of this manual.
A.	Adult Foster Care Daily Rate
This example shows a claim for a daily rate for adult foster care services.
B.	Adult Foster Care Daily Rate with Respite Care
This example shows a claim for a daily rate for adult foster care services with seven days of respite care.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-9	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Completed Claim Forms
A. Adult Foster Care Daily Rate

4. PRIOR AUTHORIZATION NO.
10
RETURN TO  |     UNISYS, P.O. BOX 9102, SOMERVILLE, MA 02145
Adult'Foster  Care,  Inc. O
25 Main Street Sometown, MA 02222 617-555-1234

~l
Commonwealth of Massachusetts
DIVISION OF MEDICAL ASSISTANCE MEDICAL SERVICES CLAIM
BILLING AGENT NO.
21 Y 2 P3VI4     5

5  SERVICING PROVIDERS NAME

S. SERVICING PROVIDER NO.	7. REFERRING PROVIDERS NAME

I. MEMBER'S NAME	10. RECIPIENT ID NO.	11. DATE OF BIRTH	12. SEX   13. OTHER   14. PATIENT ACCOUNT NO.
5r,'EMEER DEINH Til

Stephen Harvard	] 10 1 2 3 4 5 6 7 8 9|   12 01 65   | M [ ] j HarvardS

NO	YES

NO	YES

21. DIAGNOSIS CODE	22. DIAGNOSIS NAME

23. DIAGNOSIS CODE	24. DIAGNOSIS NAME

10 31 01
31
DATE 01- SLHVICL
10 01 01

DESCRIPTION OF SERVICE
Personal Care & Admi

29.       30.	31
PROCEDURE	™«T
CODE-MODIFIER	%,■    ,'U >''
X9874

1178 00

33.	34.
PAID AMOUNT	6EBB

35. REMARKS:

The person whose signature appears below cerl the statement on trie reverse side and that suet claim and ara incorporated herein. Signed under the pains and penalties o( perjury.
Robert Turner
3E. AUTHORIZED SIGNATURE

le has read     ^^^^J
iply to this	I
,11 07 01
). BILLING DATE

□	□
40. ADJUSTMENT   RESUBMITTAL    41. FORMER TRANSACTION CONTROL NO.
42. FOR OFFICE USE ONLY
□
A. ATTACHMENT CODE	B. CODE	C. CODE	D. CODE

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.3-10	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Completed Claim Forms
B.  Adult Foster Care Daily Rate with Respite Care

10
RETURN TO  |     UNISYS, P.O. BOX 9102, SOMERVILLE, MA 02145

~l
Commonwealth of Massachusetts
DIVISION OF MEDICAL ASSISTANCE MEDICAL SERVICES CLAIM

1 Main Street Anytown, MA 02222 617-555-1234

21 Y 2 P3VI4     5

BILLING AGENT NO.

4. PRIOR AUTHORIZATION NO.

5  SERVICING PROVIDERS NAME

S. SERVICING PROVIDER NO.	7. REFERRING PROVIDERS NAME

Mickey_

Arlington

T ACCOUNT NO.
j0 1 2 3 4 5 6 7 8 9| | 12 01 60| JF| f7ArlMic

15. ^^juice        J6A. tsAHESI

5r,'EMEER DEINH Til

NO	YES

NO	YES

21. DIAGNOSIS CODE	22. DIAGNOSIS NAME

23. DIAGNOSIS CODE	24. DIAGNOSIS NAME

10 31 01
DATE 01- SLHVICL
10 01 01

DESCRIPTION OF SERVICE
Personal Care & Admi

29.       30.	31
X9874_
PROCEDURE	™«T
CODE-MODIFIER	%,■    ,'U >''
31

1178

00

33.	34.
PAID AMOUNT	6EBB

10 01 01

10 18 01

Respite Care

X9873

7

266

100

35. REMARKS:

The person whose signature appears below cerl the statement on trie reverse side and that sucl claim and ara incorporated herein. Signed under the pains and penalties o( perjury.

has read      ^^^^J
iy to this	1

□	□
40. ADJUSTMENT   RESUBMITTAL    41. FORMER TRANSACTION CONTROL NO.

Robert Lynch
3E. AUTHORIZED SIGNATURE

i. BILLING DATE

42. FOR OFFICE USE ONLY
□
A. ATTACHMENT CODE	B. CODE	C. CODE	D. CODE

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-1	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Part 5. How to Read the Remittance Advice
The remittance advice is sent to providers to explain the disposition of MassHealth claims. The remittance advice lists claims in the following order: paid claims, denied claims, and suspended claims. Items within each category of claims are sorted by date of service, patient account number, and then by member last name. Three-digit errors for denied and suspended claims, amounts paid, and claim identification information are also listed. See the section on errors and descriptions elsewhere in these billing instructions for an explanation of the errors.
The first page of each remittance advice is a message page. This page provides timely information from the Division about MassHealth billing, regulation, and payment, as well as other topics. These updates must be communicated to all applicable staff, and should be kept for future reference.
Sample Remittance Advice
Pictured below is a claim form no. 9 remittance advice. An item-by-item explanation begins on the next page.

RUN    MM/DD/YY
56
PROVIDER NUMBER
REPORT PAGE
3
OTH INS
(09)
PROVIDER NAME ATTENTION LINE STREET ADDRESS CITY, STATE ZIP
1
PATIENT ACCOUNT
RECIPIENT NAME
7
8
. j _.
DIAG
22

RECIPIENT ID
9
PA  23

MEDICAL SERVICES (9) REMITTANCE ADVICE
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF MEDICAL ASSISTANCE
4
MEDICAL ASSISTANCE PROGRAM
PROVIDER PAGE
FROM DATE
TO DATE
SERVICING
PROC
CODE/
MOD
PLACE
OF SERV
UNITS
AMOUNT REQUEST
OTHER PAID
2
TCN
STATUS REMARKS
PROV NO
PAID BY MEDICAID
10
11
12 i  13  i 14 . 15 i 16 i  17 i 18 i  19  i 20 i  21
	1	L	I	l	l	1	I	l	I	
24
ERRORS  25

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-2	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Explanation of the Remittance Advice
The following list explains the items found on the remittance advice as depicted in the sample on the previous page.

 1	TO
 2	PROVIDER PAGE
 3	REPORT PAGE
4
PROVIDER NUMBER
5
RUN
DATE
PATIENT ACCOUNT NUMBER
RECIPIENT NAME
8
 9	RECIPIENT ID
 10	TCN

This is the provider’s name and address.
This is the page number of the remittance advice.
This is the page number of the entire claims processing pay cycle for all MassHealth providers.
This is the pay-to provider number that was entered in Item 2 on the claim form.
This is the number identifying the specific pay cycle. The first digit of the run number designates the claim type:
1 - MassHealth
3 - CommonHealth
5 - Massachusetts Commission for the Blind.
This is the date the remittance advice was printed.
This is the patient account number that was entered in Item 14 on the claim form.
This is the member’s name. If the member identification (ID) number is not on the MassHealth member eligibility file, or if the ID entered on the claim form was incorrect, this item states that the name is not available (NM NOT AVAIL).
This is the ID number entered on the claim form.
This transaction control number (TCN) is a unique 10-character number assigned to each claim line. The TCN is assigned when a claim is received. It is used to identify a claim for adjustments, resubmittals, and research. The following chart details each character of the sample TCN 130902744A.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-3	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Explanation of the Remittance Advice

 11	FROM DATE
 12	TO DATE
 13	SERVICING PROV NO.
 14	PROC CODE/MOD
 15	PLACE OF SERV
 16	UNITS
 17	AMOUNT REQUEST
 18	OTHER PAID AMOUNT
 19	AMOUNT PAID BY MEDICAID
20      STATUS

This is the date on which the service was provided.
The To date entered on the claim form appears here, if applicable. Otherwise, this is the same as the From date.
This is the MassHealth provider number entered in Item 6 of the claim form.
This is the code for the service that was provided.
This is the code indicating where the service was provided.
This is the number of service units (days, items, number of times performed, or time increments) that were billed.
This is the usual and customary fee entered on the claim form.
This is the amount entered on the claim form that was paid by other health insurance.
Positive amounts are paid by the Division resulting from the approval of a claim for payment or from an approved adjustment of a previously paid claim.
Negative amounts are owed by the provider to the Division resulting from an adjustment or void of a previously paid claim.
This reports the status of the claim, adjustment, or void.
PAID	- claim is paid
DENIED        - claim is not paid
SUSPEND     - claim must be reviewed prior to payment
determination ACCEPTED   - void claim is accepted

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-4	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Explanation of the Remittance Advice

21      REMARKS
 22	DIAG
 23	PA
 24	OTH INS
 25	ERRORS

This contains additional information about the claim.
CRADJ	- on an adjustment claim, the amount
previously paid is recalculated
DBADJ	- on an adjustment claim, the amount
previously paid is debited
FISCPEND    - payment is pending for fiscal reasons
ORIG	- original claim
PRRUXXX    - indicates action taken by postpayment and
provider review (PPRU) pend (“XXX”
indicates the log number assigned to the
case) RECOUP       - payment amount subtracted to satisfy an
amount owed to the Division RELFISC       - claim is released from fiscal pended status RELXXX       - released from postpayment and provider
review unit pend (“XXX” indicates the
sanction log number)
RESUB	- resubmittal of a previously denied claim
TAPE	- claim was submitted electronically
TPL-INS       - collection from other health insurance
VOID	- void to a previously paid claim
An additional character may appear in the last position in the Remarks section under the following conditions.
M	- claim was manually reviewed and
adjudicated
P	- claim was pended
S	- claim was suspended
This is the ICD-9-CM diagnosis code that was entered on the claim form.
This is the prior-authorization number that was entered on the claim form.
If an explanation of benefits (EOB) from a primary insurance carrier was attached to the claim form, the third-party-liability (TPL) carrier code corresponding to that insurer appears in this field.
The error(s) that caused the claim to suspend or deny appears here. See the section on errors and descriptions elsewhere in these billing instructions for an explanation of the error(s).

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-5	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Sample Remittance Advice Total Page
Pictured below is a sample remittance advice total page. An item-by-item explanation begins on the next page.

(09)
PROVIDER NAME ATTENTION LINE STREET ADDRESS CITY, STATE ZIP
6

PAID CLAIMS ADJUSTED CLAIMS VOIDED CLAIMS DENIED CLAIMS SUSPENDED CLAIMS PENDED CLAIMS
TOTALS

MEDICAL SERVICES (9) REMITTANCE ADVICE
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF MEDICAL ASSISTANCE
MEDICAL ASSISTANCE PROGRAM
REMITTANCE ADVICE TOTAL PAGE
PAYMENT STATUS
1
2
NUMBER OF CLAIMS
PROVIDER BILLED AMOUNT

RUN    MM/DD/YY PROVIDER NUMBER PROVIDER PAGE  REPORT PAGE
3
4
5
MEDICAID PAID AMOUNT
UNITS   OTHER PAID AMOUNT

PROVIDER RETURNS  $	OTHER RETURNS  $
RECOUPMENT ACTIVITY
RECOUPMENT ACCOUNT
PROVIDER VOUCHER AMOUNT $ 7 VOUCHER NUMBER  8 RETURN CHECK AMOUNT $

DESCRIPTION
10	CASE LOG NUMBER
11	
	CASE LOG NUMBER	
	15	

OPENING       TRANSACTIONS BALANCE       APPLIED
12         13
SANCTION ACTIVITY	
OPENING BALANCE	TRANSACTIONS APPLIED	
17
16

CLOSING BALANCE
14
18
CLOSING BALANCE

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-6	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	

Item-by-Item Explanation of the Remittance Advice Total Page
The following explains the items found on the remittance advice total page.
Payment Status
1	NUMBER OF CLAIMS	These are the total number of claims within each of the six
categories of claim status.
"	paid claims
"	adjusted claims
"	voided claims
"	denied claims
"	suspended claims
"	pended claims
2	PROVIDER BILLED AMOUNT	These are the totals of the amounts billed by the provider for
each of the six categories of claims.
3	UNITS	These are the totals of the number of payable units for each of
the six categories of claims.
4	OTHER PAID AMOUNT	These are the totals of the amounts paid by other health insurers
for each of the six categories of claims.
5	MEDICAID PAID AMOUNT	These are the totals of the amounts paid by the Division for each
of the six categories of claims.
 6	TOTALS	These are the totals for Items 1 through 5 listed above.
 7	PROVIDER VOUCHER AMOUNT	This is the amount of the payment.
 8	VOUCHER NUMBER	This is the payment reference number of the check or deposit
issued by the state treasurer’s office.
9	RECOUPMENT ACCOUNT	This is the code for the recoupment account with activity this
pay cycle.
Recoupment Activity
 10	DESCRIPTION
 11	CASE LOG NUMBER
 12	OPENING BALANCE
This is a description of the recoupment account with activity this pay cycle.
This is the case log number assigned to the recoupment account with activity this pay cycle.
This is the balance of the recoupment account at the beginning of this pay cycle.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-7	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Item-by-Item Explanation of the Remittance Advice Total Page
13	TRANSACTIONS APPLIED	This is the amount of claims activity applied to the
recoupment account this pay cycle.
14	CLOSING BALANCE	This is the balance of the recoupment account at the end of
this pay cycle.
15	CASE LOG NUMBER	This is the case log number assigned to the provider review
activity during this pay cycle.
Sanction Activity
16	OPENING BALANCE	This is the balance of the provider review account at the
beginning of this pay cycle.
17	TRANSACTIONS APPLIED	This is the amount of claims activity applied to the provider
review account this pay cycle.
18	CLOSING BALANCE	This is the balance of the provider review account at the end
of this pay cycle.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-8	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Claim Lines on the Remittance Advice A Paid Claim
In this example, adult foster care services (Service Code X9874) were provided to eligible MassHealth member John Doe from October 1, 2001 to October 31, 2001. The provider's usual fee is $1,178.00. The remittance advice claim line identifies the claim line by the transaction control number 130902744A, and lists the claim as paid and the amount paid as $1,178.00.

PATIENT ACCOUNT NUMBER
DOEJ85
DIAG

RECIPIENT NAME
DOE JOHN

RECIPIENT ID
0123456789 PA

TCN
130902744A OTH INS

FROM DATE
100101

TO DATE
SERVICING
PLACE OF SERV
UNITS
AMOUNT REQUEST
OTHER
PAID
AMOUNT
STATUS
PROC CODE/
REMARKS
PROV NO
PAID BY MEDICAID
103101] 0123456 JX9874]   99   ]     31  J1178.00J      [11178.00J PAID [    (ORIG)
ERRORS

A Denied Claim
In this example, adult foster care services (Service Code X9874) were provided to eligible MassHealth member Helen Doe from October 1, 2001 to October 31, 2001. The claim is denied with error 103, meaning “Duplicate Claim,” because a claim for the same service provided to the same member on the same date was already paid. This previously paid claim appears on the following line with the message “Conflicting Claim” and the run number of the remittance advice on which the claim was paid.

PATIENT ACCOUNT NUMBER
DOEH85	RECIPIENT NAME
DOE HELEN	RECIPIENT ID 0123456789	TCN 132302744A	FROM  ]  TO DATE  l DATE
100101 1103101	SERVICING PROV NO
1234567	PROC
CODE/
MOD
X9874	PLACE OF SERV
99	UNITS 31	AMOUNT REQUEST
1178.00	OTHER
PAID
AMOUNT	AMOUNT PAID BY MEDICAID	STATUS DENIED	REMARKS (ORIG)	
DIAG	PA	OTH INS            | ERRORS  103	
DOEH85 |DOE HELEN	0123456789	130902744AJ 100101 [103101[ 1234567 |X9874 J   99   [  31  1178.00J      [         [       j(ORIG)	
DIAG	PA	OTH INS            ■ CONFLICTING CLAIM RUN 1460	
A Suspended Claim
In this example, adult foster care services (Service Code X9874) were provided to John Smith from October 1, 2001 to October 31, 2001. The claim was suspended with error 246, meaning “Member Ineligible on Service Date.” The claim was suspended because the MassHealth member eligibility file did not list the member as eligible for the date of service. The claim will remain suspended, for a period of up to 60 days, to allow for possible updates to the MassHealth member eligibility file.

UNITS
RECIPIENT
PATIENT ACCOUNT NUMBER
SMIJ85 lSMITH JOHN

RECIPIENT ID
0123456789

TCN
130911172A

FROM i      TO DATE l   DATE
100101 1103101
.	JL	

PROC
CODE/
MOD
PROV NO
SERVICING
0123456 iX9874

PLACE OF SERV
99

AMOUNT REQUEST
31  11178.001

OTHER
PAID
AMOUNT

PAID BY MEDICAID

STATUS
REMARKS
ISUSPENDI (ORIG)

DIAG

PA

OTH INS

ERRORS 246

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-9	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Claim Lines on the Remittance Advice
Adjustments
An adjustment is indicated on a remittance advice by a debit-credit transaction. The debit (DBADJ) line reflects the original claim information, and the corresponding status field contains the amount originally paid. The credit (CRADJ) line reflects the current claim information, and the corresponding status field contains the amount that has now been paid. The amount in the “Amount Paid by Medicaid” column represents the difference between these two amounts. This amount will be zero if the adjustment did not change the original payment. If the amount is negative, it will be deducted from current and future payments made to the provider until collected in full. If the amount is positive, it will result in an additional payment for the claim.
A Positive Adjustment
In this example, a change in the number of days billed resulted in a payment increase of $38.00.

PATIENT ACCOUNT NUMBER
DOEJ85	RECIPIENT NAME
DOE JOHN	RECIPIENT ID 0185133789	TCN 132302845A	FROM  i  TO DATE  l DATE
100301 1101001	SERVICING PROV NO
0123456	PROC
CODE/
MOD
X9874	PLACE OF SERV
99	UNITS 8	AMOUNT REQUEST
30400	OTHER
PAID
AMOUNT	AMOUNT PAID BY MEDICAID
3800	STATUS 30400	REMARKS (CRADJ)	
DIAG	PA	OTH INS            ! ERRORS	
DOEJ85 | DOE JOHN	0185133789	i         ii          ii        i     i        i      i         ii
130902744A, 100301 ,100901, 0123456 ,X9874,   99   ,  7  , 26600 ,      ,         ,26600-, (DBADJ)	
DIAG	PA	OTH INS            ' ERRORS	
A Negative Adjustment
In this example, a change in the number of days billed resulted in a payment decrease of $38.00.

PATIENT ACCOUNT NUMBER
DOEJ85	RECIPIENT NAME
DOE JOHN	RECIPIENT ID 0185133789	TCN 132302845A	FROM  |  TO DATE  1 DATE
100401 1100901	SERVICING PROV NO
0123456	PROC
CODE/
MOD
X9874	PLACE OF SERV
99	UNITS 6	AMOUNT REQUEST
22800	OTHER
PAID
AMOUNT	AMOUNT PAID BY MEDICAID
3800-	STATUS 22800	REMARKS (CRADJ)	
DIAG	PA	OTH INS            | ERRORS	
DOEJ85 ! DOE JOHN	0185133789	130902744a| 100301 |100901| 0123456 |X9874|   99   \     7 \   26600 \                \                       |26600-| (DBADJ)	
DIAG	PA	OTH INS            ' ERRORS	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-10	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Claim Lines on the Remittance Advice
A Zero Adjustment Claim
In this example, the claim was adjusted to show the correct dates, resulting in no change in payment by the Division.

PATIENT ACCOUNT NUMBER
DOEJ85	RECIPIENT NAME
DOE JOHN	RECIPIENT ID 0185133789	TCN 132302845A	FROM DATE
100401	TO DATE
101001	SERVICING PROV NO
0123456	PROC
CODE/
MOD
X9874	PLACE OF SERV
99	UNITS 7	AMOUNT REQUEST
26600	OTHER
PAID
AMOUNT	AMOUNT PAID BY MEDICAID	STATUS 26600	REMARKS (CRADJ)	
DIAG	PA	OTH INS	ERRORS	
i
DOEJ85 i  DOE JOHN	0185133789	i
130902744A. 100301	i                        ii                     i              i                    i                 i                       ii
100901. 0123456 iX9874 i        99   i      7 i   26600 i                 i                       i26600-i (DBADJ)	
DIAG	PA	OTH INS	ERRORS	
A Pended Claim
In this example, it was determined that $1,178.00 was payable for this claim; however, payment is being withheld as a result of a sanction initiated by the Division’s Program Review Recoveries Unit (PRRU). A sanction inhibits the release of current payments to a provider. This claim may be released for payment when a resolution is reached between the provider and the PRRU.

PROV NO
PATIENT ACCOUNT NUMBER
DOEJ85
DIAG

RECIPIENT NAME
DOE JOHN

RECIPIENT ID
0123456789
PA

TCN
130902744A
OTH INS

FROM ,      TO DATE i   DATE
100101 ,103101
ERRORS

SERVICING
0123456

PROC
CODE/
MOD
X9874

PLACE OF SERV
99

UNITS
31

AMOUNT REQUEST
1178.00

OTHER
PAID
AMOUNT

PAID BY MEDICAID
1178.00

STATUS, REMARKS
PAID i(PRR123)

A Void
A void transaction is reported on a remittance advice to return incorrect payments, including, but not limited to, any one of the following situations:
"	payment to wrong provider;
"	payment for wrong member;
"	payment for overstated services; and
"	payment for services for which payment has been received from third-party payers.
A void transaction always results in a negative payment. These amounts are overpayments and are deducted from current and future payments made to the provider until collected in full. See the section on correcting claims for information on how to request a void to paid or pended claims.
PATIENT 'RECIPIENT'RECIPIENT ID1    TCN    ■      FROM ■      TO ■	SERV- ■   PROC ■    PLACE 'UNITS ■ AMOUNT ■ OTHER ■   AMOUNT ■    STATUS 'REMARKS
ACCOUNT |       NAME   [	[	[      DATE [   DATE [	ICING  JCODE/JOF SERVJ     JREQUESTJ PAID [  PAID BY [	[
NUMBER ii	i	ill	PROV NO i    MOD i	i	i	1AMOUNT1MEDICAID1	i
SMITHJ |     SMITHJ [   0123456789 [132302744A[    100101 [103101[	0123456 [X9874 [        99   [     31  J1178.00J      J1178.00-[ACCEPTED[   (VOID)
DIAG              '   PA         '  OTH INS            '  ERRORS

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-11	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
Examples of Claim Lines on the Remittance Advice
A Recoupment
When a claim adjustment, or a void, results in an amount due to the Division, a negative amount appears in the “Amount Paid by Medicaid” column on the remittance advice. These negative amounts are subtracted from the provider's current payment. If a negative balance is still outstanding, after the current pay cycle, the balance is carried forward as an outstanding recoupment account. In this example $1,178.00 is applied toward the outstanding balance.

PATIENT ACCOUNT NUMBER
DOEJ85	RECIPIENT NAME
DOE JOHN	RECIPIENT ID 0123456789	TCN 130902744A	FROM i      TO DATE l   DATE
100101 103101	SERVICING PROV NO
0123456	PROC
CODE/
MOD
X9874	PLACE OF SERV
99	UNITS 31	AMOUNT REQUEST
1178.00	OTHER
PAID
AMOUNT	AMOUNT PAID BY MEDICAID
1178.00	STATUS 1178.00	REMARKS (RECOUP)	
DIAG	PA	OTH INS            ]  ERRORS	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT FOSTER CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
5 BILLING INSTRUCTIONS	PAGE
5.5-12	

	TRANSMITTAL LETTER
AFC-8	DATE
10/01/01	
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