Claim Adjustment Process HP Provider Relations/October 2013
Agenda Session Objectives Types of Adjustments Adjustment Criteria Adjustment Process Web interchange Replacement Process Paper Adjustment Process Timely Filing Limitations Mailing addresses for Paper Adjustment Requests Administrative Review and Appeal procedures Void Features Helpful Tools Questions 2
Objectives Following this session, providers will be able to: Understand the different types of claim adjustments Determine when it is appropriate to file a claim adjustment Know the process of completing a claim adjustment Understand the guidelines of the filing limit for claim adjustments Have the correct mailing address for paper adjustments 3
Types of Adjustments
Types of Provider-initiated Adjustments Noncheck-related adjustments Internal control numbers (ICNs) will begin with (50) Check-related adjustments ICN will begin with (51) Provider replacement, electronic claim with attachment or claim notes, ICN will begin with (61) Provider replacement, electronic claim without attachment or claim notes, ICN will begin with (62) Provider voided claims, ICN will begin with (63) 5 Each managed care entity (MCE) establishes and communicate its own criteria for claim adjustments
Noncheck-related Adjustments Initiated by the provider due to an underpayment or an overpayment Provider does not mail a refund check with this type of adjustment Types of noncheck-related adjustments: Underpayment adjustment The adjustment was requested because the provider was underpaid Partial payment adjustment The adjustment was requested because the provider was overpaid; overpayment amount is deducted from future claim payments through an accounts receivable offset Full claim adjustment The adjustment was requested because the provider was overpaid on the entire claim; the entire claim is recouped First two digits of the ICN are 50 6
Check-related Adjustments Check-related adjustments must be completed with the paper Adjustment Request Form Provider sends a check in the amount of the excess payment with the adjustment form if an overpayment has been made Refund check First two digits of the ICN are 51 7
Electronic Replacement with Attachment or Claim Note A replacement claim is an electronic adjustment performed online using Web interchange A previously submitted claim whether electronic or paper can be replaced electronically Only noncheck-related replacements are accepted electronically ICN will begin with a 61 8
Billing Information Web interchange Quick Reference Guide 9
Attachment Process Complete all the required claim information 10
Web - Claim submission Attachments Create the attachment control number (ACN) Unique number assigned by provider Claim- and document-specific Each ACN may only be used one time Select the appropriate Report Type Code Report Type describes the document being sent Transmission Code defaults to BM (by mail) Electronic and emailed attachments are not accepted 11
Electronic Replacement without Attachment or Claim Note A claim that was submitted previously whether electronic or paper may be replaced electronically via Web InterChange ICN will begin with a 62 12
Web interchange Replacement Replacement is a change to an original claim, whether submitted the same day, same week, or a claim that has been processed previously. Original claim indicates the most recent ICN assigned to that claim An electronically submitted replacement claim can be for a previously submitted electronic or paper claim Only noncheck-related replacements are accepted electronically Check-related replacements continue to be submitted on paper 13
System Initiated Adjustments
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 First two digits of the ICN (region code) are 55 15
Mass Adjustments The Office of Medicaid Policy and Planning (OMPP), HP, Myers & Stauffer, or HMS 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 The ICN will begin with 56 16
Adjustment Criteria
Adjustment Limitations Limitations Adjustments cannot be performed for the following scenarios: Change member name Change member ID (RID) Change billing provider number/national Provider Identifier (NPI) Providers should submit a new claim to correct these types of errors A paper adjustment cannot be performed on a claim in a denied status 18
Replacement Feature Filing limits for replacements Filing limit rules apply for replacement requests Electronic claims adjusted after one year from the date of service will result in an automatic full recoupment; adjustments must be submitted using the paper adjustment form if over one year from date of service The system compares the date of service to the date of the current activity to make sure that a year has not passed Web interchange will not display a Replace This Claim button on claims more than one year from the claim s Remittance Advice (RA) date These replacements must be submitted on paper 19
Replacement Feature Filing limits for replacements If the date of service on the claim is greater than one year from the date of the replacement request, proof of timely filing is required to avoid a full recoupment of the paid amount The filing limit does not apply to crossover claims or check-related adjustments 20
Web interchange Adjustment Process
Claim Inquiry 22
Replace this Claim 23
Claim Submission Professional Detail information 24
Paper Adjustment Process
Paper Adjustment Process When to submit a paper adjustment Always submit claim adjustments via paper when: Submitting a check-related adjustment The date you are requesting the adjustment is more than one year from the date of service Past filing documentation must be submitted with the adjustment request Provider discovers the Indiana Health Coverage Programs (IHCP) overpaid on at least one detail line and the one-year filing limit has passed Providers may submit an adjustment on the overpaid detail line without causing a recoupment of the entire claim 26
Adjustment Forms Types of paper adjustment forms CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request www.indianamedicaid.com>providers>quick Links>Forms>Claim Adjustment Forms (Non-pharmacy) Instructions will print with each form UB-04 Inpatient/Outpatient Crossover Adjustment Request www.indianamedicaid.com>providers>quick Links>Forms>Claim Adjustment Forms (Non-Pharmacy) Instructions will print with each form All relevant information on the form must be completed, or the form will be returned Attach copies of the Medicare and/or Third Party Liability (TPL) remittance notices, if relevant 27
CMS-1500, Dental, Crossover Part B 28
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Adjustment Form Requirements CMS-1500, Dental, Crossover Part B PROVIDER NUMBER: Enter billing NPI or the billing Legacy Provider Identifier (LPI) with alpha location if you are an atypical provider. PROVIDER NAME/ADDRESS: Enter the current billing name, address, ZIP Code+4, and taxonomy code. CONTACT PERSON: Enter a contact name. PHONE NUMBER: Enter a current telephone number. REASON FOR ADJUSTMENT: Check the appropriate box for the reason of the adjustment. CLAIM NUMBER (ICN): Enter the ICN of the claim to be adjusted. This can be found on the RA. Please use the most current ICN for the claim to be adjusted. MEMBER ID NO.: Enter the member s 12-digit identification number (RID). DATE OF SERVICE: Enter the from and through dates of service as billed on the claim. 31
Adjustment Form Requirements CMS-1500, Dental, Crossover Part B Referring NPI/Taxonomy: Enter the referring provider NPI and taxonomy. MEMBER NAME: Enter the first and last name of the member. AMOUNT PAID: Enter the paid amount of the claim to be adjusted. REMITTANCE ADVICE DATE: Enter the date of the RA on which the claim last paid. EXPLANATION: Give a clear explanation for the requested adjustment or refund. TYPE OF ADJUSTMENT: Check the appropriate box for the type of adjustment being requested: Underpayment An adjustment to a claim requesting an additional payment, or requesting a change to the claim s data, which will result in no net change in payment. Overpayment An adjustment to a claim requesting that an overpaid amount be deducted from future payments. This can be a recoupment of a portion of the claim or the entire amount of the claim. Refund Same as overpayment except that a refund check or the overpaid amount is being submitted. A refund can be applied to a portion of the claim or to the entire amount of the claim. 32
Adjustment Form Requirements CMS-1500, Dental, Crossover Part B CLAIM TYPE: Check the appropriate box of the claim type to be adjusted. PROGRAM: Check the appropriate box of the program the claim is associated with. LINE NO.: Enter the line number of the data to be adjusted. If adjusted data is not associated with a specific line on the claim, enter a zero in this field. DESCRIPTION: Enter a brief description of the data that is to be corrected on the claim. CURRENT INFO: Enter the information as stated on the current claim that is to be adjusted. CORRECTED INFO: Enter the corrected information for the claim. Rendering NPI/Taxonomy: Enter rendering provider NPI and taxonomy. SIGNATURE: Enter the signature of an appropriate person such as a physician or billing clerk. DATE: Enter the date the request is submitted. 33
UB-04 and Inpatient/Outpatient Crossover Adjustment Request 34
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Adjustment Form Requirements UB-04 and Inpatient/Outpatient Crossover PROVIDER NUMBER: Enter billing NPI or the billing LPI with alpha location if you are an atypical provider. PROVIDER NAME/ADDRESS: Enter the current billing name, address, ZIP Code+4, and taxonomy code. CONTACT PERSON: Enter a contact name. PHONE NUMBER: Enter a current telephone number. REASON FOR ADJUSTMENT: Check the appropriate box for the reason of the adjustment. CLAIM NUMBER (ICN): Enter the ICN of the claim to be adjusted. This can be found on the RA. Please use the most current ICN for the claim to be adjusted. MEMBER ID NO.: Enter the member s 12-digit identification number (RID). DATE OF SERVICE: Enter the from and through dates of service as billed on the claim. Referring NPI/Taxonomy: Enter the referring provider NPI and taxonomy. 37
Adjustment Form Requirements UB-04 and Inpatient/Outpatient Crossover MEMBER NAME: Enter the first and last name of the member. AMOUNT PAID: Enter the paid amount of the claim to be adjusted. REMITTANCE ADVICE DATE: Enter the date of the RA on which the claim last paid. TYPE OF ADJUSTMENT: Check the appropriate box for the type of adjustment being requested: Underpayment An adjustment to a claim requesting an additional payment, or requesting a change to the claim s data, which will result in no net change in payment. Overpayment An adjustment to a claim requesting that an overpaid amount be deducted from future payments. This can be a recoupment of a portion of the claim or the entire amount of the claim. Refund Same as overpayment except that a refund check or the overpaid amount is being submitted. A refund can be applied to a portion of the claim or to the entire amount of the claim. CLAIM TYPE: Check the appropriate box of the claim type to be adjusted. 38
Adjustment Form Requirements UB-04 and Inpatient/Outpatient Crossover PROGRAM: Check the appropriate box of the program the claim is associated with. EXPLANATION: Give a clear explanation for the requested adjustment or refund. REV/PROC CODE: Enter the line number of the data to be adjusted. If adjusted data is not associated with a specific line on the claim, enter a zero in this field. DESCRIPTION: Enter a brief description of the data that is to be corrected on the claim. CURRENT INFO: Enter the information as stated on the current claim that is to be adjusted. CORRECTED INFO: Enter the corrected information for the claim. SIGNATURE: Enter the signature of an appropriate person such as a physician or billing clerk. DATE: Enter the date the request is submitted. 39
Filing Limits
Timely Filing Limitations Documentation to waive timely filing limits Commonly accepted documentation to waive timely filing limit: Dated paper RAs with bills, dated claim forms, dated letters to and from insurers or the insured Dated explanations of benefits (EOBs) from the primary insurer A print-screen of the Web interchange Claim Inquiry screen, showing all the previous submission attempts Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, dated letters and e-mails to and from the county Division of Family Resources (DFR) offices and the member Note: See IHCP Provider Manual Chapter 10 for complete past filing guidelines 41
Timely Filing Limitations Waiving the timely filing limit HP may waive the timely filing limit when the following can be documented: HP, State, or County error or action has delayed payment A member has been enrolled in the IHCP retroactively 42
Timely Filing Limitations Electronic claims Follow the guidance below to submit documentation to waive timely filing limits with electronic claims: Click the Attachments button and follow the Attachment process to mail the documentation Place supporting documentation in chronological order behind the Attachment Cover Sheet 43
Timely Filing Limitations Paper claims Submit legible and signed (if necessary) paper claims photocopies are acceptable Attach supporting documentation as needed (example: Consent for Sterilization Form) Place documentation to waive timely filing limits in chronological order behind the adjustment form Each claim must have its own documentation Address any gaps in timely filing limit documentation Use correct address; there is no separate address for timely filing limit adjustments 44
Timely Filing Limitations Processing time HP is required to process 90% of noncheck-related adjustments within 30 business days 100% of noncheck-related adjustments are required to be processed within 45 business days 45
Adjustment Mailing Addresses
Where to Submit Adjustment Requests Forward noncheck-related and underpayment adjustment requests to: HP Adjustments P.O. Box 7265 Indianapolis, IN 46207-7265 Forward check-related adjustments to: HP Refunds P.O. Box 2303, Dept. 130 Indianapolis, IN 46206-2303 Return uncashed IHCP checks to: HP Finance Unit 950 N. Meridian, Suite 1150 Indianapolis, IN 46204-4288 47
Where to Submit Adjustment Requests Send refunds for Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) claims to: HP/CA-PRTF Refunds P.O. Box 7247 Indianapolis, IN 46207 Send Money Follows the Person (MFP) refunds to: HP/MFP Refunds P.O. Box 7194 Indianapolis, IN 46207 48 Note: Do not send Adjustment Requests or claims to the Written Correspondence address
Administrative Review and Appeal Process
Administrative Review and Appeal An administrative review may be requested when a provider disagrees with the way a payment was determined or a claim was denied Before requesting an administrative review, providers must exhaust routine measures to obtain the desired payment, including: Correct billing and resubmit claim Claim adjustment When requesting an adjustment for a paid claim, include documentation explaining the reason the provider disagrees with the IHCP payment Administrative Review Inquiries should be submitted to the HP Written Correspondence Dept. Note: The above steps are not considered to be an appeal of a claim 50
Administrative Review and Appeal A formal administrative review must be filed within 60 days of notification of claim payment or denial from HP Send administrative review requests to the following address: Administrative Review HP Written Correspondence P.O. Box 7263 Indianapolis, IN 46207-7263 Providers receive a response within 90 days of the request Note: If the request for administrative review is for a National Correct Coding denial, an appeal must be filed within 60 days of the date on the Remittance Advice 51
Administrative Review and Appeal A formal appeal may be requested after the administrative review process has been exhausted Appeal requests must be made within 15 days of receipt of the final administrative review decision, to the following address: Indiana Family and Social Services Administration 402 W. Washington St., Room E034 Indianapolis, IN 46204-2773 See the IHCP Provider Manual Chapter 10, Section 6 for more information 52
Void Feature
Web interchange Void Feature 54
Void Feature Void is a Health Insurance Portability and Accountability Act (HIPAA) term for adjustment Void is the cancellation of an entire claim whether the original claim was sent the same day, same week, or a claim that has been processed previously. 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 A void can only be performed on a claim in a paid or suspended status 55
Void Feature If the voiding of a claim occurs the same day or week that the original claim was submitted, a new ICN is not created The same ICN assigned to the claim applies to the void 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 (claim already appeared on an RA), a new ICN is created The new ICN starts with 63 Examples of claim voids Change member name Change of member ID (RID) Change of billing provider NPI 56
Resources Available
Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance 1-800-577-1278 Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263 58
Q&A