Wis. ForwardHealth Online Handbook, Hospice, Topic #368

Remittance Advice

Providers receive a Claim Adjustments section in the RA (Remittance Advice) if any of their claims were adjusted during the

current financial cycle. A claim may be adjusted because one of the following occurred:

• An adjustment request was submitted by the provider.

• ForwardHealth initiated an adjustment.

• A cash refund was submitted to ForwardHealth.

To adjust a claim, ForwardHealth recoups the difference— or pays the difference— between the original claim amount and the

claim adjustment amount. This difference will be reflected on the RA.

In the Claim Adjustments section, the original claim information in the claim header is surrounded by parentheses. Information

about the claim adjustment appears directly below the original claim header information. Providers should check the Adjustment

EOB (Explanation of Benefits) code(s) for a summary of why the claim was adjusted; other header EOBs will provide additional

information.

The Claim Adjustments section only lists detail lines for a claim adjustment if that claim adjustment has detail line EOBs. This

section does not list detail lines for the original paid claim.

Note: For adjusted compound and noncompound claims, only the compound drug sections include detail lines.

Below the claim header and the detail information will be located one of three possible responses with a corresponding dollar

amount: Additional Payment, Overpayment To Be Withheld, or Refund Amount Applied. The response indicated depends on the

difference between the original claim amount and the claim adjustment amount.

If the difference is a positive dollar amount, indicating that ForwardHealth owes additional monies to the provider, then the amount

appears in the Additional Payment line.

If the difference is a negative dollar amount, indicating that the provider owes ForwardHealth additional monies, then the amount

appears in the Overpayment To Be Withheld line. ForwardHealth automatically withholds this amount from payments made to the

provider during the same financial cycle or during subsequent financial cycles, if necessary. This amount also appears in the

Financial Transactions section as an outstanding balance under Accounts Receivable.

An amount appears for Refund Amount Applied if ForwardHealth makes a payment to refund a cash receipt to a provider.