Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.11 Remittance and Status (R&S) Report : 6.11.4 R&S Report Section Explanation : 6.11.4.3 Financial Transactions

6.11.4.3
All claim refunds, reissues, voids/stops, recoupments, backup withholdings, levies, and payouts appear in this section of the R&S Report. The Financial Transactions section does not use the R&S Report form headings. Additional subheadings are printed to identify the financial transactions. The following descriptions are types of financial items.
6.11.4.3.1
This label identifies money subtracted from the provider’s current payment owed to TMHP. Specific claim data are not given on the R&S Report unless the accounts receivable control number is provided which should be referenced when corresponding with TMHP. Accounts receivable appear on the R&S Report in the following format:
Control Number. A number to reference when corresponding with TMHP.
Recoupment Rate. The percentage of the provider’s payment that is withheld each week unless the provider elects to have a specific amount withheld each week.
Maximum Periodic Recoupment Amount. The amount to be withheld each week. This area is blank if the provider elects to have a percentage withheld each week.
Original Date. The date the financial transaction was processed originally.
Original Amount. The total amount owed TMHP.
Prior Date. The date the last transaction on the accounts receivable occurred.
Prior Balance. The amount owed from a previous R&S Report.
Applied Amount. The amount subtracted from the current R&S Report.
Balance. Indicates the total outstanding accounts receivable (AR) balance that remains due to TMHP.
FYE. The fiscal year end (FYE) for cost reports.
EOB. The EOB code that corresponds to the reason code for the accounts receivable.
Patient Name. The name of the patient on the claim, if the accounts receivable are claim-specific.
Claim Number. The ICN of the original claim, if the accounts receivable are claim-specific.
Backup Withholding Penalty Information. A penalty assessed by the Internal Revenue Service (IRS) for noncompliance due to a B‑Notice. Although the current payment amount is lowered by the amount of the backup withholding, the provider’s 1099 earnings are not lowered.
Control Number. TMHP control number to reference when corresponding with TMHP.
Original Date. The date the backup withholding was set up originally.
Withheld Amount. Amount withheld (31 percent) of the provider’s checkwrite.
6.11.4.3.2
The payments withheld from a provider’s checkwrite as a result of a notice from the IRS of a levy against the provider appear in the “IRS Levy Information” section of the R&S Report. Payments are withheld until the levy is satisfied or released. Although the current payment amount is lowered by the amount of the levy payment, the provider’s 1099 earnings are not lowered. IRS levies are reported in the following format:
Control Number. TMHP control number to reference when corresponding with TMHP.
Maximum Recoupment Rate. The percentage of the provider’s payment that is withheld each week, unless the provider elects to have a specific amount withheld each week.
Maximum Recoupment Amount. The amount to be withheld periodically.
Original Date. The date the levy was set up originally.
Original Amount. The total amount owed to the IRS.
Prior Balance. The amount owed from a previous R&S Report.
Prior Date. The date the last transaction on the levy occurred.
Current Amount. The amount subtracted from the current R&S Report and paid to the IRS.
Remaining Balance. The amount still owed on the levy. (This amount becomes the “previous balance” on the next R&S Report.)
6.11.4.3.3
Refunds are identified by EOB 00124, “Thank you for your refund; your 1099 liability has been credited.” This statement is verification that dollars refunded to TMHP for incorrect payments have been received and posted. The provider’s check number and the date of the check are printed on the R&S Report. Claim refunds appear on the R&S Report in the following format:
ICN. The claim number of the claim to which the refund was applied this cycle.
Patient Name. The first name, middle initial, and last name of the patient on the applicable claim.
Medicaid Number. The patient’s Medicaid or CSHCN Services Program number.
Date of Service. The format MMDDCCYY (month, day, and year) in “From” DOS.
Total Billed. The total amount billed for the claim being refunded.
Amount Applied This Cycle. The refund amount applied to the claim.
EOB. Corresponds to the reason code assigned.
Control Number. A control number to reference when corresponding with TMHP.
FYE. The fiscal year for which this refund is applicable.
EOB. Corresponds to the reason code assigned.
6.11.4.3.4
Payouts are dollars TMHP owes to the provider. TMHP processes two types of payouts: system payouts that increase the weekly check amount and manual payouts that result in a separate check being sent to the provider. Specific claim data are not given on the R&S Report for payouts. A control number is given, which should be referenced when corresponding with TMHP. System and manual payouts appear on the R&S Report in the following format:
Payout Control Number. A control number to reference when corresponding with TMHP.
Payout Amount. The amount of the payout.
FYE. The fiscal year for which the payout is applicable.
EOB. Corresponds to the reason code assigned.
Patient Name. Name of the patient (if available).
PCN. Medicaid number of the patient (if available).
DOS. Date of service (if available).
6.11.4.3.5
The provider’s 1099 earnings are not affected by reissues. A messages states, “Your payment has been increased by the amount indicated below:
Check Number. The number of the original check.
Check Amount. The amount of the original check.
R&S Number. The number of the original R&S Report.
R&S Date. The date of the original R&S Report.
6.11.4.3.6
The provider’s 1099 earnings are credited by the amount of the voided/stopped payment.
Check Number. The number of the voided/stopped payment.
Check Amount. The amount of the voided/stopped payment.
R&S Number. The number of the voided/stopped payment.
R&S Date. The date of the voided/stopped payment.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.