Download - Paid Claim Adjustment Procedures, Voids, and Replacementsprovider.indianamedicaid.com/media/28981/paid claim adjustment... · PAID CLAIM ADJUSTMENT PROCEDURES, VOIDS, AND REPLACEMENTS

October 2007

Presentation by

EDS Provider Field Consultants

Paid Claim Adjustment Procedures,Voids, and Replacements

PAID CLAIM ADJUSTMENT PROCEDURES, VOIDS, AND REPLACEMENTS2 / OCTOBER 2007

Agenda

• Session Objectives• Types of Adjustments• When to Submit an Adjustment Request• Adjustment Forms• Adjustment Filing Limitations• Waiver of Filing Limit• Past Filing Limit Documentation• How to Submit Claims for Filing Limit Waiver

• Where to Submit Adjustment Requests• Timely Processing Guidelines• Void and Replacement Features• Helpful Tools• Questions


Session Objectives

• Understand what a paid claim adjustment is

• Determine when and how to file a paid claim adjustment

• Understand the different types of paid claim adjustments

• Learn how various adjustments are identified in the internal control number (ICN)

• See the format and instructions for paid claim adjustment forms

• Understand filing limit considerations for adjustments, voids, and replacements

• Maximize knowledge of the Web InterchangeVoid and Replacement functions


Types of Adjustments

• Check-related adjustments

• Non-check-related adjustments

• Retroactive rate adjustments

• Mass adjustments

• Voids and Replacements

• Reprocessing (Region 80)

Each managed care organization (MCO) may establish and communicate its own criteria for claim adjustments


Check-related Adjustments

• Initiated when a provider has been overpaid

• Provider sends a check in the amount of the excess payment with the adjustment form and appropriate documentation

• Also referred to as a refund, can be for a partial payment or the entire payment on a claim

• First two digits of the ICN (region code) are 51


Non-check-related Adjustments

• Initiated by the provider due to an underpayment or an overpayment

• Does not include a refund check from the provider

• Types of non-check-related adjustments:

–Underpayment adjustment – the adjustment was requested because the provider was underpaid

–Overpayment adjustment – the adjustment was requested because the provider was overpaid; overpayment amount is deducted from future claim payments through an accounts receivable offset

–Full Overpayment adjustment – an overpayment adjustment, when the entire claim is recouped



Retroactive Rate Adjustments

• The rate-setting contractor for long-term care facilities initiates retroactive rate adjustments

• Retroactive rate adjustments are a result of minimum data set (MDS) field audits

• Claims paid for the dates of service affected are reprocessed, and can result in increased or decreased payments



Mass Adjustments

• The Office of Medicaid Policy and Planning (OMPP), EDS, or Affiliated Computer Services (ACS) can initiate a mass adjustment

• Mass adjustment requests are applied to change a large number of paid claims at one time

• Mass adjustments can apply to many providers, or just one provider

• Mass adjustments can be used when a system problem caused claims to be paid incorrectly, or when a rate for a procedure code changed retroactively



When to Submit an Adjustment Request

• A paper adjustment request for a previously paid claim can be submitted only when an incorrect or partial payment has been made on a claim, including a claim that paid at zero dollars

• Line item denials must be billed as a new claim and cannot be submitted as an adjustment–Exceptions are when the specific

services must be billed together, such as transportation base rate and mileage, multiple surgeries, and room and board with leave days


Adjustment Forms

• Types of adjustment forms–CMS-1500, Dental, Crossover Part B Paid Claim Adjustment

Request

–UB-92 Inpatient/Outpatient Crossover Adjustment Request

–Pharmacy Paid Claim Adjustment Request

• All relevant information on the form must be completed, or the form will be returned

• Attach copies of the original claim and the Medicare and/or Third Party Liability (TPL) remittance notices

• The ICN of the most recently adjusted claim must be included on the adjustment request


CMS-1500, Dental, Crossover Part B Paid ClaimCMS - 1500, DENTAL, CROSSOVER PART B PAID CLAIM ADJUSTMENT REQUEST

INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION Mail completed requests to: EDS - Adjustments, P.O. Box 7265, Indianapolis, IN 46207-7265

(1) PROVIDER NUMBER: (2) REASON FOR ADJUSTMENT: (Check appropriate Box)

PROVIDER NAME/ADDRESS: Change TPL Amt. Change Patient Deductible Amt. Offset or Refund of entire claim amount

(Please check block 10)

PHONE NUMBER: Change information as indicated in blocks 13-16

CONTACT PERSON: Medicare Adjustment (Attach all EOMBs that apply to this adjustment)

(3) CLAIM NUMBER (ICN) (4) MEMBER ID NO. (5) DATE OF SERVICE From Thru

(6) MEMBER NAME (7) AMOUNT PAID (8) REMITTANCE ADVICE DATE (9) GIVE COMPLETE EXPLANATION OF ADJUSTMENT OR REFUND REQUEST:

(10) TYPE OF ADJUSTMENT (11) CLAIM TYPE (12) PROGRAM Underpayment Adjustment CMS - 1500 Medicaid Overpayment Adjustment (Deduct from future payments) Dental CSHCS Refund Adjustment (Check attached) Crossover ARCH

Check number: 590

PLEASE LIST THE INFORMATION TO BE CORRECTED IN THE BLOCKS BELOW. IF NO LINE NO. IS ASSOCIATED WITH THE CORRECTION, PLEASE ENTER A ZERO (0) IN THE LINE NUMBER FIELD. FOR EXAMPLE, TPL APPLIED WOULD ALWAYS BE LINE # 0.

(13) LINE NO.

(14) DESCRIPTION OF INFORMATION TO BE CORRECTED

(15) CURRENT INFORMATION

(16) CORRECTED INFORMATION

(17) SIGNATURE: (18) DATE:


Adjustment Form ProblemsReturns to Provider

• No approved prior authorization on file

• Claim in denied status

• Procedure code units vs. billed amount

• ICN not the most recent

• No primary insurance EOB for TPL adjustments

• Requests to override benefit limitations

• Non-specific narratives


Adjustment Limitations

• Adjustments cannot be performed for the following scenarios:–Change member name

–Change member ID (RID)

–Change billing provider number/NPI

–Change patient liability amount (LTC)

–Change net billed amount (TPL claims)

–Change co-pay information

–Change certification code (Medicaid Select)

Providers should submit a new claim to correct these types of errors


Ordering Paid Claim Adjustment Forms

• Examples of paid claim adjustment request forms are available at www.indianamedicaid.com

• Order forms from:EDS Forms RequestP.O. Box 7263Indianapolis, IN 46207-7263

http://www.indianamedicaid.com/


Adjustment Filing Limitations

• The EDS Adjustment Unit must receive non-pharmacy paid claim adjustment requests within one year of the last processing action

• When a payment is made by Medicare, a crossover claim is not subject to the one-year filing limit

• Medicare denied services are not considered crossover claims, and therefore are not exempt from the one-year filing limitation

• Providers may obtain a waiver of the one-year filing limit for adjustment requests by providing the appropriate documentation with the request


Waiver of Filing Limit

• EDS may waive filing limit due to extenuating circumstances when the following can be documented:–EDS, state, or county error or action has delayed payment

–The provider has made reasonable and continuous attempts to resolve a claim problem

–The provider has made reasonable and continuous attempts to bill and collect from a TPL, before billing the IHCP

–Medicare paid claims have failed to cross over

–A member has been enrolled in the IHCP retroactively

–A provider has been enrolled in the IHCP retroactively

• Claims not filed timely because the provider misplaced them, office personnel has changed, or the provider forgot to file are not considered extenuating circumstances and result in rejection of the claim


Past Filing Limit Documentation

• Commonly accepted documentation to waive filing limit–Dated paper RAs with ICNs, bills, claim forms,

letters to and from insurers or the insured

–Dated EOBs from the primary insurer

–A print-screen of the Web interChange claim inquiry screen, showing all the times the claim has been filed

–Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, letters to and from the county offices, EDS field consultants, and the member


How to Submit Claims for Filing Limit Waiver

• Submit legible and signed (if necessary) paper claims with the appropriate documentation – photocopies are acceptable

• Attach required supporting documentation

• Place supporting documentation in chronological order

• Attach individual documentation trail to each claim

• Use correct address for claim type; there is no separate address for filing limit claims– NOTE: Do not send claims to the Written

Correspondence address

• Address any gaps in filing limit documentation


Where to Submit Adjustment Requests

• Forward non-check-related and underpayment adjustment requests to:EDS AdjustmentsP.O. Box 7265Indianapolis, IN 46207-7265

• Forward check-related adjustments to:EDS RefundsP.O. Box 2303, Dept. 130Indianapolis, IN 46206-2303

ACS State Healthcare, ACS-Indiana Drug Rebate

P.O. Box 2011332Dallas, TX 75320-1332

EDS Finance DepartmentReturning IHCP Checks950 N. MeridianIndianapolis, IN 46204-4288


Where to Submit Adjustment Requests

•Send refunds for pharmacy claims to:ACS State Healthcare-Indiana Adjustments

P.O. Box 201376

Dallas, TX 75320-1376

•Send pharmacy adjustments to:Indiana Pharmacy Adjustment

C/O ACS

P.O. Box 502327

Atlanta, GA 31150


Timely Processing Guidelines

• EDS is required to process 90 percent of non-check-related adjustments within 30 days

• EDS is required to process 100 percent of non-check-related adjustments within 45 days

• Providers should contact EDS Customer Service if an adjustment does not appear on an RA within 45 days of submission, plus mail time

• Providers should contact ACS for questions regarding pharmacy adjustments


Void and Replacement FeaturesVoid



• Void requests can be submitted electronically using the 837 transaction or Web interChange

• Void requests submitted electronically can be for a previously submitted electronic claim or paper claim

• Voids cannot be performed on a claim in a denied status

• Void is a HIPAA term for adjustment

• Void is the cancellation of an entire claim whether same day, same week, or post financial



• If the original claim being voided is in a paid or suspended status, and it is the same day or same week – a new claim is not created.

• The same ICN is used.

• The original claim denies with edit 0120 – Claim denied due to an electronic void request.

• If the original claim being voided is a historical claim, a new claim is created.

• The new ICN starts with 63.

• Check-related voids (adjustments) continue to be submitted on paper.



Pre-Financial Post-Financial

2007010000002 – Paid

User voids the claim

Voided claim denies EOB 0120

2007242001001 – Paid

Today’s date: 10/10/07

6307252001000 – Denied with EOB 0120

RA/835 shows:

Claim shows on the denied page only – same ICN.

RA/835 shows:

Mother Claim: 2007242001001 and Daughter Claim: 6307252001000

Both appear on the adjustment page.


Void and Replacement FeaturesReplacement



• Replacement is a change to an original claim, whether same day, same week, or post financial–Original Claim indicates the most recent

ICN assigned to that claim

• Replacement is a HIPAA term for adjustment



• An electronically submitted replacement claim can be for a previously submitted electronic or paper claim

• Only non-check-related replacements are accepted electronically

• Check-related replacements (adjustments) continue to be submitted on paper



• If the Indiana Health Coverage Programs (IHCP) receives a replacement claim for an original claim that has been through a financial process (has appeared on an RA), the replacement claim ICN starts with one of the following:–61 - Provider-initiated replacement

containing attachments and/or claim notes

–62 - Provider-initiated replacement with no attachments and/or claim notes


Void and Replacement FeaturesFiling Limits for Voids and Replacements

• No filing limit for void requests

• One-year filing limit for replacement requests–The system compares the last date of claim activity and the

date of the current activity to make sure that a year has not passed.

–If the replacement is greater than one year, the request is rejected and edit 0285 appears on the Biller Summary Report for electronic data interchange (EDI) submitted claims.

–Web interChange will not display a replacement button on claims that are past the filing limit. These replacements must be submitted on paper.

–The filing limit does not apply to crossover claims.


Void and Replacement FeaturesEdits for Voids and Replacements

• 0120 – Claim denied due to an electronically submitted void

• 0121 – Claim denied due to an electronically submitted replacement


Correcting a Claimweb interChange v. Paper

• Providers are encouraged to perform all adjustment activities via web interChange–Reminder: Do not use the Replace This Claim

feature more than one year from the date of service

–Always submit paper adjustments after one year from the date of service to avoid undesired recoupments

• Do not submit duplicate adjustment requests


Modifications to Duplicate Logic

• IndianaAIM now reads all five digits of the procedure code andall modifiers

• Applicable to claims and replacement claims received on or after September 27, 2007

• Applicable to the following claim types:–Medical–Medical Crossover Part B–Outpatient–Outpatient Crossover C–Home Health

• Effective August 1, 2007:–Crossover claims billed on a CMS-1500 claim form no longer deny

with edits 5007 (exact duplicate, header), or 5008 (suspect duplicate, header)

–These claims now emulate the possible, and exact duplicate logic applied to medical claims, which apply the 5000 (possible duplicate), and 5001 (exact duplicate) edits


Modifications to Duplicate Logic

Example 1:

10/25/07 73560 LT10/25/07 73560 RT

Example 2:

10/26/07 H0044 HW HQ AH10/26/07 H0044 HW HQ HE

The second detail line will no longer deny as a duplicate to the first detail line


Helpful ToolsAvenues of Resolution

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

• Customer Assistance

• Written Correspondence

• Provider Field Consultant

http://www.indianamedicaid.com/


Questions

October 2007

EDS

950 N. Meridian St., Suite 1150

Indianapolis, IN 46204

EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2007 Electronic Data Systems Corporation. All rights reserved.

Download - Paid Claim Adjustment Procedures, Voids, and Replacementsprovider.indianamedicaid.com/media/28981/paid claim adjustment... · PAID CLAIM ADJUSTMENT PROCEDURES, VOIDS, AND REPLACEMENTS

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