Top Provider Questions – Adjustments / Cancels
Click on an item to expand or Show All / Close All
- When should a claim be adjusted?
-
When providers determine that information on a processed or rejected claim needs to be changed, an adjustment is appropriate if the claim information was posted to the Common Working File (CWF). Examples of such instances would be to add or remove a visit or service on a claim, or to change the patient status code originally submitted to Medicare. Review Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual for instructions on completing adjustments using FISS. In addition, refer to the Adjustments/Cancels Web page for more information.
Reviewed 12/20/2022
-
- If my claim rejects, should I submit an adjustment?
-
Making the decision to submit an adjustment depends on the reason why your claim rejected and whether the claim information was posted to the Common Working File (CWF). If the claim information did not post to CWF, you can submit a new claim with the corrected information. To determine whether the information posted to CWF, you will need to view the information in the TPE-TO-TPE (tape-to-tape) field, which can be viewed on the Fiscal Intermediary Standard System (FISS) MAP171D. For more information about accessing MAP171D, see the instructions for using the "Claims (Option 12)" option in Chapter Three – Inquiry Menu of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual. The letter "X" in the TPE-TO-TPE field indicates that the original rejected claim data did not post to CWF. In this case, it would be appropriate to submit a new claim with the corrected information, instead of submitting an adjustment. If the TPE-TO-TPE field is blank, the rejected claim did post information to CWF, and an adjustment should be submitted in this situation.
Claims that reject as duplicates should not be adjusted, cancelled or resubmitted to Medicare. Claims that reject for eligibility or other billing errors may be appropriate to adjust once the eligibility or billing issue is resolved.
Reviewed 12/20/2022
-
- Are there any special steps that must be completed in order to adjust a rejected claim?
-
In most cases, the only difference between adjusting a rejected claim and adjusting a paid claim occurs when using the Fiscal Intermediary Standard System (FISS) for online adjustments. When claims reject, charges are placed into the "NCOV CHARGES" (non-covered charges) field on FISS page 02. Because of this, the revenue detail lines must be deleted and added back by re-entering the revenue code, HCPCS, units, charges, and service date information in new detail lines. See Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual for instructions on deleting and adding revenue code lines.
Reviewed 12/20/2022
-
- If a claim is partially denied, can I submit an electronic adjustment? If so, can FISS be used to adjust the claim?
-
Yes. Providers can choose to submit electronic adjustments for partially denied claims using FISS or their batch file transfer software. NOTE: Adjustments can only be made to paid lines. Adjustments cannot be made to any part of a denied line. If you are disputing a denied charge, an appeal must be submitted to Medicare.
Reviewed 12/20/2022
-
- What is the process for electronically submitting an adjustment to a partially denied claim?
-
Providers should be aware that only the paid (covered) lines of a partially denied claim can be adjusted. To submit an adjustment to the paid lines of a partially denied claim using the Fiscal Intermediary Standard System (FISS), please use the following steps:
Step One: Access the claim via FISS using the Claim Adjustment Menu Options (33 if HHA; 35 if hospice agency). The Claim Adjustment Menu can be accessed from the FISS Main Menu by entering "03" in the "ENTER MENU SELECTION" field and pressing . Step Two: Select the partially denied claim you wish to adjust. Step Three: Make the needed changes to the paid lines. Step Four: Use a Claim Change Reason Code (CCRC) on FISS page 01 and Adjustment Reason Code (ARC) on FISS page 03, which reflects the reason for the adjustment. A listing of these codes is available in Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual. Step Five: Include "Remarks" on FISS page 04, indicating the reason why you are submitting the adjustment. Step Six: Press the F9 key to submit the adjustment. Step Seven: Use FISS Inquiry Option 12 to monitor the status of your adjustment as it processes through the system. Once processed, it will appear in FISS status/location P B9997. For additional information about monitoring Medicare claim status, see the instructions in Chapter Three – Inquiry Menu of the FISS DDE User Manual. Reviewed 12/20/2022
-
- What additional claim data is required for adjustments?
-
The correct type of bill for any adjustment should end with "7". Examples: 817, 827, 327. If you are using FISS to adjust the claim, the system updates the adjustment with the appropriate type of bill. The type of bill is entered into field locator (FL) 4.
A Claim Change Reason Code (CCRC) is entered in the first available Condition Codes field (FL 18-28). A listing of claim change reason codes used for claims adjustment is available in Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual.
Enter the Document Control Number (DCN) of the claim you are adjusting in FL 64. This information can be found in the "DCN" field on MAP171D or on the Remittance Advice (RA) you received when the original claim processed. If using FISS to adjust the claim, the system automatically populates the DCN field of the adjustment with the original claim's DCN. For more information about accessing MAP171D, see the instructions for using the "Claims (Option 12)" option in Chapter Three – Inquiry Menu of the FISS DDE User Manual.
If submitting the adjustment using FISS, enter an Adjustment Reason Code in the ADJUSTMENT REASON CODE field on FISS page 03. For common adjustment reason codes, refer to the Claims Correction Menu (Chapter 5) of the FISS DDE User Manual.
Explain why you are submitting the adjustment in the Remarks field (FL 80) or FISS page 04. NOTE: if "D9" (any other change or multiple changes) is the appropriate CCRC for your Medicare adjustment, remarks are required when submitting the billing transaction.
This information is also available on the Adjustments/Cancels web page.
Reviewed 12/20/2022
-
- A Fiscal Intermediary Standard System (FISS) adjustment was made to my home health claim due to an updated Medicare Advantage (MA) plan enrollment period. However, the adjustment rejected, and we didn't receive any Medicare payment. Can I cancel the adjustment and resubmit the claim to get paid for the dates of service?
-
It is never appropriate for home health agencies (HHAs) to attempt to cancel a system-generated adjustment. Canceling the claim creates billing issues as the original episode/period of care remains posted to the Common Working File (CWF). In addition, unnecessary costs are created to the Medicare program by requiring manual intervention from CGS staff and the staff responsible for maintaining the CWF to resolve the billing errors. HHAs should be aware that FISS makes adjustments to home health claims for a variety of reasons. Most commonly, these occur to appropriately pay a shortened episode/period of care with a Partial Episode Payment (PEP) when a transfer, discharge/readmission, or a beneficiary's enrollment in a Medicare Advantage (MA) plan takes place. These adjustments can be identified by their type of bill (TOB) 32G.
In the situation where the original home health claim was adjusted by FISS due to a beneficiary's enrollment in an MA plan AND the system adjustment posted claim information to CWF when it rejected, providers may submit an adjustment – TOB 327 – to the rejected 32G TOB, so that the dates of service that were coverable under "traditional" Medicare benefits (Part A and B) can be processed.
For more information on how to submit an adjustment, please see the detailed instructions found in Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual. Please be aware that payment cannot be made under Medicare Part A or Part B for dates of service falling within a beneficiary's enrollment in an MA plan, unless the beneficiary has also elected the Medicare hospice benefit.
NOTE: in some situations where a claim rejects due to the beneficiary's MA plan enrollment, an electronic adjustment may not be appropriate, and you may need to submit a paper adjustment or resubmit a new claim with the correct dates of service. If the billing software your home health agency uses automatically submits cancel claims for FISS-generated adjustments, we encourage you to speak with your software vendor to resolve this billing error.
Reviewed 12/20/2022
-
- We are required to submit claims electronically. Is it ever permissible for us to submit a paper adjustment?
-
Yes, there are limited situations in which a paper adjustment is allowed or required to be submitted. Refer to the Submitting Paper Claims Web page for additional information.
Reviewed 12/20/2022
-
- We received a duplicate payment for a claim. How can we correct this?
-
At different times billing transactions that have previously processed may need to be canceled. Examples of such instances would be to correct the beneficiary's Medicare number, or provider number the claim was billed or paid with, or repay a duplicate Medicare payment. Home health providers may need to cancel Requests for Anticipated Payment (RAPs) or final claims to remove episode/period of care information from the Common Working File (CWF). Review Chapter Five – Claims Correction of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) User Manual for instructions on completing cancels using FISS. Refer to the Adjustment/Cancel web page for additional information about canceling a Notice of Election or Benefit Period, and home health claims/RAPs.
Reviewed 12/20/2022
-
- I have a claim in RTP that the type of bill has an "I" or "G" as the third digit. I know that this indicates the adjustment was created by CGS. Can I suppress this claim?
-
No. Providers should not suppress the view of an adjustment in the Return to Provider (RTP) file (status/location T B9997) when the third digit of the type of bill is an "I" or "G" (XXI or XXG). Instead, review the reason code and make the necessary correction and then F9 the adjustment to continue processing. If you suppress the view, the adjustment will not be processed and payment will be delayed.
Reviewed 12/20/2022
-