CMS-1500 Adjustment Remark Codes: Understanding AT05, AT99, and AT26 for Billing

In the complex world of medical billing, accurate claim submission is paramount. CMS-1500 adjustment remark codes play a critical role in communicating specific information to payers, ensuring that claims are processed correctly and efficiently. Understanding these codes, particularly AT05, AT99, and AT26, is essential for healthcare providers to avoid delays, rejections, and maximize revenue. This guide provides detailed explanations and best practices for using these important attachment type codes for various billing scenarios, including Medicare, commercial insurance, and newborn claims.

What Are CMS-1500 Adjustment Remark Codes?

Adjustment remark codes, also known as attachment type codes, are used on the CMS-1500 claim form to indicate that additional documentation or specific remarks are attached to the claim. These codes help payers quickly identify the nature of the attached information, which is often crucial for processing complex or unusual claims. Proper use of these codes can significantly improve your CMS-1500 claim adjustments process and overall efficiency in healthcare billing.

Decoding Attachment Type Code AT05: Medicare Crossover Scenarios

The AT05 attachment type code is specifically used when a claim, primarily for Medicare beneficiaries, requires supplemental information regarding Medicare payment or non-crossover situations. This is particularly relevant in contexts such as ambulance billing forms AT05 where specific attachments may be required.

Original Instruction: If the recipient has coverage through Medicare Part B and MA, this claim should automatically cross over to MA for payment of any applicable deductible or co-insurance. However, if the claim does not cross over from Medicare and you are submitting the claim directly to MA, enter AT05 in Block 19 and attach a completed “Supplemental Medicare Attachment for Providers” form (MA-539) to the claim.

Expanded Explanation: There are several reasons why a Medicare claim might not automatically cross over to Medicaid (MA) as expected, necessitating the use of AT05. These can include:

• Data Entry Errors: Incorrect or incomplete beneficiary information on the original Medicare claim.
• Coordination of Benefits (COB) Issues: Primary and secondary payer information may be incorrectly sequenced or missing, preventing automated crossover.
• Specific Plan Rules: Certain Medicare Advantage plans or state Medicaid programs may have unique crossover rules or require prior authorization that was not obtained for the service.
• System Glitches: Occasional technical issues between Medicare and Medicaid systems can temporarily prevent automatic claim crossover.

When you encounter a non-crossover situation, applying AT05 signals to the MA payer that the attached MA-539 form provides the necessary details about the Medicare payment (or lack thereof), allowing for proper processing of the MA portion of the claim. Always ensure the MA-539 form is accurately and completely filled out to prevent further delays.

When using AT05, remember to properly complete and attach the “Supplemental Medicare Attachment for Providers” form (MA-539).

Using Attachment Type Code AT99: Providing Essential Remarks for Commercial and Other Claims

The AT99 attachment type code indicates that additional remarks are attached to the claim. This code is versatile and used across various billing scenarios, including those for commercial insurance. When using AT10 for commercial insurance payments, always remember to properly complete and attach the “Supplemental Attachment for Commercial Insurance for Providers” form (MA-538).

Best Practices for AT99 Remarks:

When utilizing AT99, ensure your remarks are clear, concise, and provide all necessary information for the payer to understand the claim’s specifics. Remarks must be placed on an 8-1/2″ x 11″ sheet of white paper securely clipped to your claim. Always include your provider number and the recipient’s number on the top left-hand corner of the remarks page.

Concrete examples of remarks that might be required on an attached sheet include:

• A detailed explanation for an appeal or claim reconsideration request.
• Clarification of unusual circumstances surrounding a procedure or visit that might not be evident from standard coding.
• Supporting documentation for medical necessity when standard codes or existing documentation are deemed insufficient by the payer.
• Additional information explicitly required by a specific payer policy or contractual agreement.

These detailed remarks, submitted using the correct attachment type codes, ensure that the payer has a complete picture, significantly reducing the likelihood of claim denials and speeding up processing for various scenarios that require additional context beyond the standard claim form fields.

Understanding AT26 for Newborn Billing and Temporary Eligibility

The AT26 attachment type code is specifically used in conjunction with AT99 when billing for newborns who have temporary eligibility under the mother’s recipient number. This scenario is common in the initial period after birth before the newborn receives their own unique identification and insurance policy.

Temporary Eligibility for Newborns:

Newborns are often covered under their mother’s insurance plan for a limited time immediately after birth. This temporary eligibility period allows sufficient time for the parents to enroll the newborn in their own insurance plan. During this crucial period, the mother’s insurance information is utilized for the newborn’s medical services.

Why Mother’s Information is Required:

To correctly process claims for newborns with temporary eligibility, payers require specific information about the mother to link the newborn’s services to the mother’s policy. On the remarks sheet (indicated by AT99), you must include the mother’s full name, date of birth, and social security number. This detailed information helps verify coverage and ensures accurate claim adjudication, which is critical for smooth newborn billing AT26 procedures.

Common Questions About Newborn Billing with AT26

• Q: How long does temporary eligibility typically last?
  A: The duration varies by insurance plan and state regulations, but it commonly ranges from 30 to 60 days post-birth. It’s crucial for parents to enroll the newborn in their own plan within this timeframe to avoid coverage gaps.
• Q: What if the mother’s insurance changes or terminates during the temporary eligibility period?
  A: This can complicate billing. It is essential to verify the mother’s current insurance status before submitting claims and to inform the payer of any changes promptly. In some cases, manual intervention or resubmission may be required.
• Q: Are there specific guidelines for different types of insurance (e.g., Medicare, Medicaid, commercial) regarding newborn temporary eligibility?
  A: Yes, each payer type may have slightly different rules and requirements. Always consult the specific payer’s guidelines or provider manual for the most accurate information on newborn billing AT26 and associated processes.

General Guidelines for CMS-1500 Claim Adjustments

If you are submitting an adjustment to a previously paid CMS-1500 claim (as referenced in Block 22), you must paper clip an 8-1/2″ by 11″ sheet of paper to the paper claim form containing a clear and concise explanation as to why you are submitting the claim adjustment. This applies to various scenarios, from correcting billing errors to updating patient information or reflecting new service details.

For a complete listing and description of Attachment Type Codes, please refer to the CMS-1500 Claim Form Desk Reference, which may be located in Appendix A of a specific payer’s handbook or a general industry guide. Always consult the most current and relevant documentation for accurate information on Medicare remark codes explanation and other detailed billing instructions.

Specific Requirements for Qualified Small Businesses (Pennsylvania)

It is important to note that the following instruction applies specifically to Qualified Small Businesses operating within Pennsylvania, as defined by the 4 Pa Code §2.32. This regulation outlines specific criteria for businesses classified as small and has particular implications for billing practices within the state. This requirement may not be applicable to providers in other states.

Qualified small businesses must always enter the following message in Block 19 (Reserved for Local Use) of the CMS-1500, in addition to any applicable attachment type codes:

• “(Name of Vendor) is a qualified small business concern as defined in 4 Pa Code §2.32.”