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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
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
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
Visit MedMutual.com
Visit MedMutual.com
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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: __________________________________________________________________________________________________________
Policy Holders Name: ________________________________ Patient Name: ____________________________ Date of Service: ________________
Claim or Check #: ________________________________ Certificate Nbr:____________________________ Amt of Refund: _________________
Reason for Refund: __________________________________________________________________________________________________________
Policy Holders Name: ________________________________ Patient Name: ____________________________ Date of Service: ________________
Claim or Check #: ________________________________ Certificate Nbr:____________________________ Amt of Refund: _________________
Reason for Refund: __________________________________________________________________________________________________________
Policy Holders Name: ________________________________ Patient Name: ____________________________ Date of Service: ________________
Claim or Check #: ________________________________ Certificate Nbr:____________________________ Amt of Refund: _________________
Reason for Refund: __________________________________________________________________________________________________________
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
Visit MedMutual.com
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
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
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
Note: Carolina Care Plan providers may contact the Call Center at 800/315-3143
Section X
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
2060 East Ninth StreetCleveland, Ohio 44115-1355
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
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
Visit MedMutual.com
DATE03-20-2008PAYEE NUMBER861234567-002ACCOUNT ID01
PAGE1
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
7
BackaDJustmeNt reasoN coDe leGeND
t82 aDDitioNal/late iNFormatioN/charGes suBmitteD
sample aDJustmeNt summary Form continued
Section X
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
2060 East Ninth StreetCleveland, Ohio 44115-1355
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
2060 East Ninth StreetCleveland, Ohio 44115-1355
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
INVOICE NUMBER: 6074-00119
INVOICE DATE: MAR 15, 2008
MAR 15, 2008
112233445-002
MAR 1, 2008
113.33
Visit MedMutual.com
2060 East Ninth StreetCleveland, Ohio 44115-1355
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
www.medmutual.com
FAMILY MEDICAL CENTERPO BOX 44997CLEVELAND, OH 44115-1022
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
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
12
sample Notice oF paymeNt iNvoice statemeNt
0105
113.33 -
SUPERMED PLUSP. O.BOX 6018CLEVELAND, OH 441011-800-362-1278
PATIENT NAME: CARDHOLDER, JANE
FAMILY MEDICAL CENTERPO BOX 44997CLEVELAND, OH 44145-1022
NOTICE OF PAYMENT2060 East Ninth StreetCleveland, Ohio 44115-1355
Visit MedMutual.com
Medical Mutual Of Ohio • Medical Mutual Services, LLCMedical Mutual Services is a wholly owned subsidiary of Medical Mutual of Ohio
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
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
SECTION X — Notice of Payment Notice of Payment Schedule — Professional Providers
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