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 or NOEs with an incorrect date of admission 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:
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). Due to a change in the way FISS processes provider-submitted cancels to rejected claims, home health and hospice agencies will need to check FISS using Inquiry Option 12 to ensure their cancel has finalized prior to resubmitting the services to Medicare.
Cancel/RAPs claims must include the following information, in addition to the usual field locators:
CGS performs four types of reopenings:
Review the information available on the Reopening webpage to determine the appropriate process to follow when submitting these types of requests.
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, or the "Limitation on Recoupment (935)" CGS Web page.
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