MOA

Outpatient Adjudication Information

Pos: 035

Max: 1

Detail - Optional

Loop: 2100

Elements: 9

Ref	Id	Element Name	Req	Type	Min/Max	Usage
MOA01	954	Percent Description: Percentage expressed as a decimal Industry: Reimbursement Rate Use this number for the reimbursement rate. This does not apply to claims processed by Medicare Carriers.	O	R	1/10	Situational
MOA02	782	Monetary Amount Description: Monetary amount Industry: Claim HCPCS Payable Amount Use this monetary amount for the HCPCS payable amount. This does not apply to claims processed by Medicare Carriers.	O	R	1/18	Situational
MOA03	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Remark Code Used when a Remittance Remark Code applies to this claim.	O	AN	1/30	Situational

MOA04

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Remark Code
See MOA03.
Used when additional remittance remarks apply to this claim.

1/30

Situational

MOA05

127

1/30

Situational

MOA06

127

1/30

Situational

MOA07

127

1/30

Situational

	MOA08	782	Monetary Amount Description: Monetary amount Industry: Claim ESRD Payment Amount Use this monetary amount for the ESRD payment amount. This does not apply to claims processed by Medicare Carriers.	O	R	1/18	Situational
	MOA09	782	Monetary Amount Description: Monetary amount Industry: Nonpayable Professional Component Amount Use this monetary amount for the professional component amount billed but not payable. This does not apply to claims processed by Medicare Carriers.	O	R	1/18	Situational

1.	MOA01 is the reimbursement rate.
2.	MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
3.	MOA03 is the Claim Payment Remark Code. See Code Source 411.
4.	MOA04 is the Claim Payment Remark Code. See Code Source 411.
5.	MOA05 is the Claim Payment Remark Code. See Code Source 411.
6.	MOA06 is the Claim Payment Remark Code. See Code Source 411.
7.	MOA07 is the Claim Payment Remark Code. See Code Source 411.
8.	MOA08 is the End Stage Renal Disease (ESRD) payment amount.
9.	MOA09 is the professional component amount billed but not payable.

Notes:

1. This segment should be generated by Medicare carriers or Intermediaries.
2. Either MIA or MOA will appear, but not both.
3. All situational quantities and amounts in this segment are required when the value of the item is different than zero.
4. Payers and payees outside of Medicare community may need to use this segment.

Example:

MOA***MA01~

	ExternalCodeList
	Name: 411
	Description: Remittance Remark Codes