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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 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:


Data
UB-04 Fiscal Intermediary Standard System (FISS)
Form Locator (FL) Data Field
(FISS Page #)
Data
Type of Bill FL 4 3rd digit = 7
327-home health
817 or 827-hospice
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
* When D9 is used, an explanation of the adjustment must be included in the Remarks field (FL 80).
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

* When D9 is used, an explanation of the adjustment must be included in the Remarks field (FISS Claim Page 04).
Document Control Number FL64 Document Control Number (DCN) of the claim being adjusted DCN (FISS Page 01) DCN of claim being adjusted (done automatically by FISS when using Claim Adjustments option 33 or 35)
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 (required when Claim Change Reason Code D9 is reported) REMARKS (FISS Page 04) Remarks indicating reason for adjustment (required when Claim Change Reason Code D9 is reported)

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 claims/RAPs 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
328-home health
818 or 828-hospice
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
Document Control Number FL64 Document Control Number (DCN) of the claim being canceled DCN (FISS Page 01) DCN of claim being canceled (done automatically by FISS when using Claim Adjustments option 53 or 55)
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

Reopenings

CGS performs four types of reopenings:

  • Claim Correction Reopening (beyond the claims timely filing limit);
  • Untimely Filing (rejected claims (R B9997) with reason code 39011)
  • 56900 Reopenings (denials due to no medical review additional development request (ADR) documentation received by CGS); and
  • Ordering/Referring Denial Reopenings (home health only).

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 §200External PDF, or the "Limitation on Recoupment (935)" CGS Web page.

Resources

Updated: 08.16.17


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