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Quick Reference
Guide for Filing
Adjustment and
Cancel Claims
Updated: February 2008
Table of Contents
Adjustment and Cancel Claims .............................................................................3
General Information...........................................................................................3
Billing Instructions for hardcopy adjustment claims ...........................................5
Billing Instructions for hardcopy cancel claims ..................................................7
Adjustments via DDE ........................................................................................8
Cancels via DDE ...............................................................................................9
References .........................................................................................................10
Appendix.............................................................................................................11
Chart ...............................................................................................................11
Updated: February 2008
Adjustment and Cancel Claims
General Information
Adjustment requests are the most common mechanism for changing a
previously accepted bill. If a provider fails to include a particular item or service
on its initial claim, an adjustment submission to include such an item(s) or
service(s) is not permitted after the expiration of the time limitation for filing of the
initial claim.
There are special timeliness requirements for filing adjustment requests for
inpatient services subject to a prospective payment system, if the adjustment
results in a change to a higher weighted DRG. These adjustments must be
submitted within 60 days of the date of the remittance for the original claim, or
the adjustment will be rejected.
However, to the extent that an adjustment bill otherwise corrects or supplements
information previously submitted on a timely claim about specified services or
items furnished to a specified individual, it is subject to the rules governing
administrative finality, rather than the time limitation for filing. (Chapter 34 on
Reopenings)
Adjustment to a partially-denied claim.
If a line item on a claim has been denied by Medical Review, whether it is
beneficiary or provider liable, it cannot be altered in any way regardless of the
circumstances for which it was denied.
If a provider wishes to add charges to a partially-denied claim, or change a line
item that was not denied on a partially-denied claim, without altering the line
item(s) that have been denied, an adjustment may be submitted electronically.
Both units and charges for line items that were denied by Medical Review on the
original claim must remain non-covered when submitting an adjustment.
If a claim is fully denied by Medical Review, or a provider wishes to change a line
item that was originally denied by Medical Review on a partially-denied claim, the
provider should request an appeal. (Reference: Provider Notice 02-036)
Updated: February 2008
Cancel requests are acceptable in cases of incorrect provider identification
numbers and incorrect HICNs. Cancellation is a specialized type of adjustment in
which a previously finalized claim is voided.
While electronic adjustment and cancel requests are preferred, these may also
be submitted on a hardcopy UB-04 by small providers who are permitted to bill
on paper per the Administrative Simplification Compliance Act.
Overlap situations
• Claim is submitted and subsequently rejected or returned to the provider
(RTP) because it overlaps a previously processed claim that was either
fully denied or partially denied by medical review. You must submit a
hardcopy cancel request to the fully or partially denied claim along with an
explanation for the cancel in the remarks section of the claim. Please refer
to the billing instructions for hardcopy claims section of this quick
reference guide.
• An inpatient hospital admission is returned because it overlaps a
previously processed outpatient claim with a date of service within 72
hours or 24 hours of the inpatient hospital admission date. Regulations
require the bundling of outpatient services to the inpatient hospital claim
when the outpatient services are rendered within 72 hours of an inpatient
admission to a hospital subject to the inpatient hospital prospective
payment system (IPPS) or within 24 hours of an admission to a hospital
excluded from IPPS, such as inpatient rehabilitation facilities (IRF) or
units, psychiatric hospitals or units, long-term care hospitals (LTCH),
children’s hospitals and cancer hospitals. (CMS Pub. 100-04, Ch. 3, 40.3)
In this situation, the outpatient claim must be cancelled and all services
and charges must be added to the inpatient hospital claim. Please refer to
the EMC cancel instructions of this quick reference guide.
If an outpatient claim is returned because it overlaps a previously
processed inpatient claim and the date of service is within 72/24 hours of
the inpatient admission, the inpatient claim must be adjusted to add
services and charges from the outpatient claim. Please refer to the EMC
adjustment instructions of this quick reference guide.
Note: Do not cancel a Medicare Secondary Payer (MSP) claim. This process
adversely impacts contractor reporting requirements to CMS. These must be
submitted as adjustments.
Updated: February 2008
Billing Instructions for hardcopy adjustment claims
All of the claim's original data must be supplied; the desired change must be
made; and the Type of Bill, Claim Change Reason and Adjustment Reason
codes must indicate that adjustment processing is to be done.
The table below identifies the specific entries required when doing an
adjustment. Please note that data changes needed in any particular case
depends upon the situation and will not be noted here. The usage of claim
change reason condition code D9 requires remarks to be listed on page 4.
Locator Entry/Instructions
4 Type of Bill XX7
>>>>>>>>>>>>>>>>>>> Complete claim data (with
changes highlighted)
18-28 Condition Code Claim Change Reason
Code*, as applicable:
D0 Change to service date
D1 Change in charges
D2 Change in revenue or
HCPCS codes
D3 Second/subsequent
interim PPS bill
D4 Change in Diagnosis
and/or Procedure
D7 Change to make
Medicare the secondary
payer
D8 Change to make
Medicare the primary payer
D9 Any other adjustment
change
E0 Change in patient status
Updated: February 2008
Billing Instructions for hardcopy adjustment claims (cont)
Locator Entry/Instructions
64Document Control Number The DCN of the original
(DCN), A, B or C claim
80 Remarks The Adjustment Reason
Code to be used:
**
AU Automobile
BL Black Lung
CB Credit Balance
DS Discharge Status
change
ES ESRD
HD HMO Disenrollment
HP HMO Pay
IC Non-billable revenue
code/Invalid revenue
code
LS Length of Stay denial,
no payment
LW Length of Stay denial,
payable per waiver
OT Other Change
PH Public Health Service
(PHS), MSP Value
Code 16
VA Veterans'
Administration
WC Worker's
Compensation
WE Working Elderly
If Adjustment Reason
Code OT is used, a
remark indicating the
reason for the adjustment
* Do not submit more than one claim change reason code per adjustment request. Choose the
single reason that best describes the adjustment.
Use claim change reason code D1 only when the charges are the only change on the claim.
Other claim change reasons frequently change charges, but the provider may not “add” reason
code D1 when this occurs.
** For a complete list of Adjustment Reason Codes, see the FISS Training Guide through the
following link: www.highmarkmedicareservices.com/parta/provider/manuals/fiss/fiss_guide.pdf
Updated: February 2008
Billing Instructions for hardcopy cancel claims
All of the claim's original data must be supplied; the Type of Bill and Claim
Change Reason must indicate that cancel processing is to be done.
The table below identifies the specific entries required when doing a cancel.
Please be aware that the data change needed in any particular case
depends upon the situation and will not be noted here.
Locator Entry/Instructions
4 Type of Bill XX8
>>>>>>>>>>>>>>>>>>> Complete claim data
18-28 Condition Code Claim Change Reason
Code, as applicable:
D5 Cancel to correct HICN
or provider ID
Note: Submit a corrected
replacement bill after
submitting the cancel-only
request.
D6 Cancel only to repay a
duplicate or OIG
overpayment
64Document Control Number The DCN of the original
(DCN), A, B or C claim
Updated: February 2008
The following instructions are to be used when submitting an
adjustment or cancel request through the FISS DDE function.
Adjustments via DDE
Select 03 Claims Correction
30 Inpatient Claim
31 Outpatient Claim
Key the HIC # and dates of service
Select the claim to be adjusted by placing a ‘S’ next to the claim
Key condition code D0-D4, D7-D9 or E0 on page 1
Key adjustments reason code on page 3 (SC 16)
Make corrections to claim
Key remarks on page 4 if using condition code D9 and adjustment reason code
OT
Key F9 to store the adjustment claim
Updated: February 2008
Cancels via DDE
Select 03 Claims Correction
50 Inpatient Claim
51 Outpatient Claim
Key the HIC # and dates of service
Select the claim to be canceled by placing a ‘S’ next to the claim
Key condition code: D5-D6 on page
Key F9 to store the cancelled claim
Updated: February 2008
References
CMS IOM Publication 100-04, Chapter 1, Sections 70.5 & 130
CMS IOM Publication 100-04, Chapter 3, section 40.3
Fiscal Intermediary Shared System (FISS) Training Manual
Updated: February 2008
Appendix
Chart
IF AND THEN
There is an X in the tape
to tape field on page 2, Resubmit a new claim
Original claim
F2 (MAP 171D)
fully Rejected
The tape to tape field on
(RB9997)
page 2, F2 (MAP 171D) Electronically adjust the claim
does not have an X.
Electronically adjust the claim. Adjust line by
keying a 'D' in the first position of the revenue
Rejected line needs
Original claim code on the line that needs correcting, press
correcting
partially Rejected the home key and then enter. Rekey the new
(Line item line below the total line (0001).
reject(s)) Line other than a
rejected line needs Electronically adjust the other lines.
correcting
Submit the Medicare Part A Redetermination
Original claim
Request Form to the Appeals Department
fully Denied N/A
http://www.highmarkmedicareservices.com/part
(DB9997)
a/forms
Denied line has a clerical
error such as,
Submit the Clerical Error Reopening Request
transposed
Form to the Appeals Department
procedure/diagnosis
http://www.highmarkmedicareservices.com/part
code, data entry error
a/forms
that needs correcting or
Original claim missing diagnosis code.
partially Denied Submit the Medicare Part A Redetermination
(Line item Provider disagrees with Request Form to the Appeals Department
denial(s)) line denial http://www.highmarkmedicareservices.com/part
a/forms
Electronically submit adjustment. Both units
and charges for line items that were denied by
Line other than a line
Medical Review on the original claim must
denial needs correcting
remain non-covered when submitting an
adjustment.
Provider wishes
The claim has MSP DO NOT CANCEL - provider must make an
to cancel the
involvement adjustment
claim
Overlap situation Claim was fully or Send hardcopy cancel request with remarks.
Note: Exception to Administrative Simplification
requires a cancel partially denied Compliance Act (ASCA) electronic billing requirements.
Updated: February 2008
