Reimbursement Pro contains OnDemand EOB™ that creates a patient-specific EOB
on-demand. No more will your staff need to file, find, copy, mark up, and recopy EOBs. And you
can use the “Ordered EOBs” option to create a specific batch of patient-specific EOBs in the
EXACT ORDER that your secondary bills are printed! Your secondary person simply puts your
EOBs with HCFA 1500s and they are done! Saves lots of money on copier costs and labor.
CAHABA GBA-MS PART B MEDICARE
P.O. BOX 548 REMITTANCE
BIRMINGHAM, AL 352010548 NOTICE
PROVIDER #: 3000018
PAGE #: Page 1 of 1
CHECK/EFT #: 2000084
PERF PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD
NAME: HALL, SCOTT HIC: 100005427 ACNT: 115898-3 ICN: 0208079194750 ASG Y MOA: MA01
5000000088 0304 030408 11 1 93015 333.00 0.00 0.00 0.00 OA24 333.00 0.00
5000000088 0304 030408 11 1 78465 1,448.00 0.00 0.00 0.00 OA24 1,448.00 0.00
5000000088 0304 030408 11 1 78478 253.00 0.00 0.00 0.00 OA24 253.00 0.00
5000000088 0304 030408 11 1 78480 252.00 0.00 0.00 0.00 OA24 252.00 0.00
5000000088 0304 030408 11 2 J0152 342.00 0.00 0.00 0.00 OA24 342.00 0.00
5000000088 0304 030408 11 2 A9500 360.00 0.00 0.00 0.00 OA24 360.00 0.00
PT RESP 0.00 CLAIM TOTAL 2,988.00 0.00 0.00 0.00 2,988.00 0.00
ADJ TO TOTALS: PREV PD 0.00 INTEREST 0.00 LATE FILING CHARGE 0.00 NET 0.00
GLOSSARY: GROUP, REASON, MOA, REMARK AND REASON CODES
OA24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. This change to be
effective 4/1/2008: Charges are covered under a capitation agreement/managed care plan.
MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we
are fair toyou, we require another individual that did not process your initial claim to conduct the appeal. However, in
order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you
have a good reason for being late.
In order to comply with HIPAA privacy regulations, this patient-specific Medicare Remittance Notice has been independently reproduced by RemitDATA, Inc. It
was created from a Medicare Electronic Remittance Advice (ERA) in accordance with the standard paper remittance format stipulated by CMS.
RemitDATA’s new “Q” is the FUTURE of reimbursement management! Managers can pull up the overall
Q, and then assign rules so that work is sorted into each collector’s individual Q. Collectors then log into
their specific Q and work and update their denials. Managers are able to monitor the overall Q, and track
the workload and performance of all the team members.
Reimbursement Pro contains “Q”, our new powerful work-flow management tool. Now,
instead of working from paper EOBs, or from existing printed reports, collectors simply log
into their “Q” each morning to begin working their denials. From the Q, they can work
denials, pull patient-specific EOBs, create Review Forms, add status notes, transfer to other
users, and more. Managers can then track the results via Q reports and User Performance
metrics. Q is truly the future of working denials. You have to try it to believe it!
RemitDATA’s new “Q” allows you to drill down into the Patient Specific denial screen, where you can review the
details of the claim, print up a patient-specific EOB, see all previous denials and history for the claim or patient,
create a review or other OnDemand Form, update the status, assign to other users, and much, much more! With
WebScan Pro integration, you can easily retrieve needed documents to attach to the claim for resubmission!!
Reimbursement Pro offers OnDemand Form which allows quick generation of various short pay letters,
dunning letters and review forms. Forms can be complete and ready to send with just a few key strokes
and mouse clicks!
Reimbursement Pro contains OnDemand Forms™, which eliminates the need to
manually complete Review Forms and more. Our easy-to-use online version takes a
FRACTION of the time of the paper-based version, AND is guaranteed to be 100%
accurate (many manually completed Review forms contain multiple errors due to the
mind-numbing process of copying data by hand). Simply find the claim(s) you want to
review, and then use the auto-populate tools to complete the form and click “Generate
Review”. AND, if you are a WebScan™ client, then you can attach any documents which
have been scanned into the system! Another huge time-saver. See page 1.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE REDETERMINATION REQUEST FORM
COLLINS, STEPHEN E
1. Beneficiary’s Name:_____________________________________________________________________
2. Medicare Number: ______________________________________________________________________
3. Description of Item or Service in Question: __________________________________________________
9330726, 9332026, 9332526
03/13/2008, 03/13/2008, 03/13/2008
4. Date the Service or Item was Received: _____________________________________________________
5. I do not agree with the determination of my claim. MY REASONS ARE:
Insert reason here!!!!
6. Date of the initial determination notice ______________________________________________________
(If you received your initial determination notice more than 120 days ago, include your reason for not making this request earlier.)
7. Additional Information Medicare Should Consider: ____________________________________________
8. Requester’s Name:______________________________________________________________________
9. Requester’s Relationship to the Beneficiary: _________________________________________________
10. Requester’s Address: ____________________________________________________________________
11. Requester’s Telephone Number: ___________________________________________________________
12. Requester’s Signature: ___________________________________________________________________
13. Date Signed: __________________________________________________________________________
14. J I have evidence to submit. (Attach such evidence to this form.)
J I do not have evidence to submit.
NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon
conviction be subject to fine or imprisonment under Federal Law.
Form CMS-20027 (05/05) EF 04435/2005
Don’t forget our other innovative web-based solutions to help
your practice achieve optimal efficiency!
WebScan™ is a powerful, document management solution that works via the web. All you
need to get started is a scanner and stuff to scan! Simply scan a batch of documents (CMNs,
EOBs, Invoices, Employment Documents, AP Info, Patient Satisfaction Surveys, etc.) into a
network folder and WebScan™ automatically detects the new batch and uploads it to your
account on one of our 100% HIPAA Secure servers located in our state-of-the-art data center.
Sales PRO™ is the leading web-based software program for the homecare industry
allowing sales and marketing professionals to track, evaluate and monitor their work.
Sales PRO™ tracks how to best reach your accounts, a continuous call report for
accounts, key account issues and so much more.