Quick Reference Guide for Filing Adjustment and Cancel Claims by Armaggedon

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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

								
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