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Claims Remittance Tracking Report

Last Update: January 2005

The Remittance Summary displays the number of claims and associated dollar amounts remitted to a Provider during a reporting period by the Board (MACSIS Company) responsible for the remittance. "Remitted" means the claims were adjudicated in MACSIS and included on a paper and/or electronic remittance advice (ERA/835) made available to the Board for forwarding to the Provider. Note this does not necessarily mean the claims were "paid" by check or voucher since such payments are often disbursed at a later time by a Board's County Auditor.

The "AP DATE" displayed is the date the claim is final (adjudicated) in MACSIS. Within a week those claims will/should appear on a remittance advice forwarded by the responsible Board to the Provider. Please keep in mind there will be a delay between the "AP Date" and when the Provider receives the Remittance Advice, however this should not be a "significant" delay (i.e., several weeks). If a Provider has not received a Remittance Advice as listed on this report and it has been several weeks, the Provider should contact the responsible Board and request clarification.

The HTML report pages are produced by a SAS (C) program running against the weekly Master File. The following definitions and comments apply (italicized information relates to definitions and concepts of the MACSIS Diamond 725 database).

DEFINITIONS:

  1. Fiscal Year
    Remittance transaction totals are displayed by State Fiscal Year (July 1 through June 30) based on the claim date of service for the current and prior year.

    Claims are assigned to a SFY (State Fiscal Year) on the basis of the Date of Service -- in Diamond 725 terms, the "Claims Primary Date" found both on the Professional Claims Header (JUTILHM0) and Professional Claims Detail (JUTILDM0) records. If the date of service precedes the prior fiscal year, it is excluded from the report.
  2. Funding Stream (Medicaid .vs. Non-Medicaid)
    A claim is assigned to Medicaid .vs. Non-Medicaid depending on characteristics of the client, service, and even provider. If the client is potentially Medicaid Eligible and the service being remitted is a potentially Medicaid Eligible service, then the claim will be categorized as "Medicaid." Otherwise it will be included under "Non-Medicaid." Please note that the Ohio Department of Jobs and Family Services (ODJFS) can later determine that a claim paid (within Diamond) as "Medicaid" was not eligible for Medicaid payment and would ask for a "reverse" of the (Diamond) remittance.

    A claim is assigned to Medicaid .vs. Non on the basis of the "MEDEF" (Medical Definition) value on the Claims Detail record. For Mental Health claims, MEDEF values greater than 1000 and less than 1899 are considered "Medicaid." All other are Non-Medicaid. For ODADAS claims, MEDEF values greater than or equal to 5000 and less than or equal to 5999 are considered Medicaid. Missing values for MEDEF would be considered Non-Medicaid claims for both State Departments.

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  3. UPI
    The 5-digit Unique Provider Identifier assigned by the Board to identify a provider/agency/site.

    UPI is what Diamond 725 refers to as Provider Number as found on the Claims Header record. The leading zeroes ordinarily seen in the variable have been removed to save space in the report presentation. Note: This is not the MACSIS Vendor Number but Provider Number.
  4. Board
    The five character code identifying the Board (Company) responsible for the adjudicated claim. The Board assignment is based on the client's county of residence (as defined in MACSIS).

    Company refers to "Company Code" as found on the Claims Detail Record.
  5. AP DATE
    This is the date the claim is marked for payment within MACSIS. Please keep in mind there can be a delay between the "AP Date" and when the Provider receives a remittance advice (or electronic equivalent). The AP date does not pertain to the date the Provider may receive the check for the services from the Board's County Auditor nor does it pertain to the date the claim may be further adjudicated by ODJFS.

    This field refers to the POSTDATE from the SAS Master Claims Program. This date is valued during the APUPD (Accounts Payable Update) process in Diamond. Only remittance transactions with a POSTDATE occurring in the reporting period are included.

    Note: For claims finalized near month-end, it is possible for a claim to have a POSTDATE in one month, but the corresponding remittance advice (ERA/835) to be created in the next month.In this case, the remittance file name will have a julian date occurring in the month after the POSTDATE.To reconcile remittance advice files to this report, refer to the POSTDATE values contained in the files rather than the file creation julian date.POSTDATE values are reported as:
    • Paper Remittance Advice: AP Check Date
    • MACSIS 835 Health Care Claim/Payment Advice:DTM02(Production Date) when DTM01 = 405
    • Electronic Remittance Advice (ERA): Field 61

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  6. Claims (Remitted)
    The number of claims remitted by the Board on the designated AP Date.

    This includes claims with a Diamond processing status of “P” (Paid) and “F” (Finalized). “F” claims are claims that have been through APUPD (Accounts Payable Update) but have not completed the Diamond Check Print/Check Post (CKPRT/CKPST) process because the total due the provider is either a zero or negative amount. The latter can occur when all claims are denied and/or more claims are reversed then paid for a provider on a designated AP Date.
  7. Remit Amount
    This is a summary of the Net Amount Remitted for those claims included in this report. Note: Claims with a net amount of zero are included here.

    This field refers to the sum of the Net Amount Paid (netamt) on the Professional Claims Detail Record (JUTILDM0).

COMMENTS:

  1. This Claims Tracking Remittance Report will be produced the weekend following the end of a Calendar month and will be retained for display here for three months. There are no plans for prior reporting at this time.
  2. The SAS (c) program used in the report is available upon request.