Adjustments/Cancels
Adjustment claims (type of bill XX7) are submitted when it is necessary to change information on a previously processed claim. The change must impact the processing of the original bill or additional bills in order for the adjustment to be performed. The claim being adjusted must be in a finalized status location (i.e., P B9997 or R B9997).
If a claim in a P status has been reviewed by Medical Review and has one or more line items denied, adjustments can be made to the paid line items. Please note: Adjustments cannot be made to any part of a denied line item on a partially paid claim.
In addition, only rejected claims (R B9997) that have posted information to the Common Working File (CWF) should be adjusted, such as a claim that rejected due to an open Medicare Secondary Payer (MSP) record or a home health date of service that overlaps a beneficiary's stay in an inpatient facility.
It is not appropriate to adjust home health Requests for Anticipated Payment (RAPs) or hospice Notices of Election (NOEs). Incorrect RAPs and NOEs must be canceled and rebilled with the correct information. Additional information for hospice providers can be found on the Canceling a Notice of Election or Benefit Period web page.
Adjustment claims must include the following information, in addition to the usual field locators and the information that you are adjusting:
| Data | UB-04 | Fiscal Intermediary Standard System (FISS) | ||
|---|---|---|---|---|
| Form Locator (FL) | Data | Field (FISS Page #) |
Data | |
| Type of Bill | FL 4 | 3rd digit = 7 (i.e., 327 or 817) | TOB (FISS Page 01) | 3rd digit = 7 (done automatically by FISS) |
| Claim Change Reason Code | FL 18-28 | D0 – change dates of service D1 – change charges D2 – change revenue/HCPCS code D9 –Other/multiple changes E0 – change patient status |
COND CODE (FISS Page 01) | D0 – change dates of service D1 – change charges D2 – change revenue/HCPCS code D9 –Other/multiple changes E0 – change patient status |
| Total Charges | FL 47 | Enter changes to charges. | TOT CHARGE (FISS Page 02) | N/A unless adjusting a rejected claim. If rejected, all revenue code lines must be deleted and rekeyed to show charges as covered (TOT CHARGE field). |
| Adjustment Reason Code | N/A | ADJUSTMENT REASON CODE (FISS Page 03) | RF – change dates of service RG – change charges RH – change revenue/HCPCS code RM –Other/multiple changes RN – change patient status |
|
| Remarks | FL 80 | Remarks indicating reason for adjustment | REMARKS (FISS Page 04) | Remarks indicating reason for adjustment |
Cancel claims/RAPs (type of bill XX8) may be necessary when the incorrect provider number was submitted, an incorrect HICN was submitted, or a duplicate payment was received. Home health agencies may need to cancel RAPs for reasons such as removing an episode from the CWF that was submitted and processed with an incorrect Health Insurance Prospective Payment System (HIPPS) code, or service date on the 0023 line. Claims/RAPs needing canceled must be in a finalized status/location (P B9997).
Cancel/RAPs claims must include the following information, in addition to the usual field locators:
| Data | UB-04 | Fiscal Intermediary Standard System (FISS) | ||
|---|---|---|---|---|
| Form Locator (FL) | Data | Field (FISS Page #) |
Data | |
| Type of Bill | FL 4 | 3rd digit = 8 (i.e., 328 or 818) | TOB (FISS Page 01) | 3rd digit = 8 (done automatically by FISS) |
| Claim Change Reason Code | FL 18-28 | D5 – cancel to correct provider/HIC# D6 – cancel duplicate payment |
COND CODE (FISS Page 01) | D5 – cancel to correct provider/HIC# D6 – cancel duplicate payment |
| Adjustment Reason Code | N/A | ADJUSTMENT REASON CODE (FISS Page 03) | RI – cancel to correct provider/HIC # RJ – cancel duplicate payment |
|
| Remarks | FL 80 | Remarks indicating reason for cancel | REMARKS (FISS Page 04) | Remarks indicating reason for cancel |
Limitation on Recoupment (935) Overpayments
The limitation on recoupment (935), as required by Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) changes the process by which CGS can recoup an overpayment resulting from a post payment adjustment, such as a denial or Medicare Secondary Payer (MSP) recovery. For additional information, refer to the Medicare Financial Management Manual, (CMS Pub. 100-06), Ch. 3 §200.
Resources
- Refer to the Claims Correction Menu (Chapter 5) of the Fiscal Intermediary Standard System (FISS) Guide for information about how to submit claim adjustments or cancellations using FISS.
- Adjustments/Cancel Frequently Asked Questions (FAQs)
- Home health providers
- Hospice providers
Updated: 12.20.12
