claim adjustment helpful tips for a successful outcome

HP Provider RelationsOctober 2011

Claim Adjustment Helpful Tips for a Successful Outcome

Claim Adjustment Process October 20112

Agenda

– Session Objectives

– Types of Adjustments• Provider-initiated• HP-initiated

– Void Feature

– Adjustment Criteria

– Adjustment Process• Paper Adjustment Process• Timely Filing Limitations• Where to Submit Paper Adjustment Requests

• Administrative Review and Appeal

– Helpful Tools

– Questions


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

– Define the process to complete a claim adjustment

– Understand the impact of the filing limit on a claim adjustment

DefineTypes of Adjustments


Types of Provider-initiated Adjustments

– Noncheck-related adjustments (50)

– Check-related adjustments (51)

– Provider replacement, electronic claim with attachment or claim notes (61)

– Provider replacement, electronic claim with out attachment or claim notes (62)

Each managed care entity (MCE) may establish and communicate its own criteria for claim adjustments


Noncheck-related Adjustments

– Provider does not mail a refund check with the adjustment request

– Initiated by the provider due to an underpayment or an overpayment

– 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 internal control number (ICN)(region code) are 50


Check-related Adjustments

– Check-related adjustments must be completed via 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

– Also referred to as a refund

– First two digits of the ICN (region code) are 51


Web interChange Replacement Feature


– A replacement claim is an adjustment performed online

– An electronically submitted replacement claim can be performed for a previously submitted electronic or paper claim

– Only noncheck-related replacements are accepted electronically

– 61 – Provider-initiated replacement containing attachments and/or claim notes

Replacement Electronic with Attachment or Claim Note


Electronic Attachment Process Reference


– An electronically submitted replacement claim can be performed for a previously submitted electronic or paper claim

• 62 – Provider-initiated replacement with no attachments and/or claim notes

Replacement Electronic without Attachment or Claim Note


Types of HP-initiated Adjustments

– Mass Replacement Nursing Facility (55)

– Mass Replacement Financial (56)

– Mass Replacement by HP (57)

– Mass Reprocessing (58)


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


Mass Adjustments

– The Office of Medicaid Policy and Planning (OMPP), HP, or Affiliated Computer Services (ACS) 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

– First two digits of the ICN (region code) are 56, 57, and 58

ClarifyVoid Feature


Web interChange Void Feature


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 post-financial

– 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


Void Feature

– If the void 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

UnderstandAdjustment Criteria


Adjustment 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

Limitations


Replacement Feature

– Filing limit rules apply for replacement requests• Electronic claims adjusted after one year from the date of service will result in a

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

–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

Filing limits for replacements

LearnAdjustment Process


Paper Adjustment Process

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

When to submit a paper adjustment


Adjustment Forms

– Types of paper adjustment forms

• CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request

• UB-04 Inpatient/Outpatient Crossover Adjustment Request

– 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 necessary


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 Thru Dates of Service as billed on the claim.

Adjustment Form Requirements



– Referring NPI/Taxonomy: Enter the Referring provider NPI and taxonomy. If the claim was submitted prior to the NPI implementation with a Referring LPI, the NPI/Taxonomy is required for all healthcare claims.

– 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.




– 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. If the claim was submitted prior to the NPI implementation with a Rendering LPI, the NPI/Taxonomy is required for all healthcare claims.

– SIGNATURE: Enter the signature of an appropriate person such as a physician or billing clerk.

– DATE: Enter the date the request is submitted.



UB-04 and Inpatient/Outpatient Crossover Adjustment Request


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 Thru Dates of Service as billed on the claim.

– Referring NPI/Taxonomy: Enter the Referring provider NPI and taxonomy. If the claim was submitted prior to the NPI implementation with a Referring LPI, the NPI/Taxonomy is required for all healthcare claims.




– 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.




– 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.



Adjustment Form RTP

Paper adjustments are returned to the provider unprocessed for the following types of requests:

–Claim in denied status

–No primary insurance explanation of benefits (EOB) for TPL adjustments

–Requests to override benefit limitations

–Nonspecific narratives

–No approved prior authorization on file

Return to provider


Timely Filing Limitations

– The HP Adjustment Unit must receive nonpharmacy paid claim adjustment requests within one year of the last processing action

– When a service is allowed by Medicare, a crossover claim is not subject to the one-year filing limit

– Medicare-denied services are not considered crossover services, and therefore are not exempt from the one-year filing limitation

– Providers may obtain a waiver of the one-year filing limit for adjustment requests by providing past filing documentation with the request



– Commonly accepted documentation to waive filing limit

• Dated paper RAs with bills, dated claim forms, dated letters to and from insurers or the insured

• Dated 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, HP field consultants, and the member

Past filing documentation



HP may waive the filing limit due when the following can be documented:

– HP, state, or county error or action has delayed payment

– The provider has made reasonable and continuous attempts to resolve a claim problem

– The provider has made reasonable and continuous attempts to bill and collect from a TPL, before billing the IHCP

– A member has been enrolled in the IHCP retroactively

– A provider has been enrolled in the IHCP retroactively

Waiving the filing limit



Follow the guidance below to submit past filing documentation with electronic claims:

–Click the Attachments button and follow the Attachment process to mail the past filing documentation

–Place supporting documentation in chronological order behind the Attachment Cover Sheet

–Address any gaps in filing limit documentation

Electronic claims



– Submit legible and signed (if necessary) paper claims – photocopies are acceptable

– Attach supporting documentation as needed (example: Sterilization Consent Form)

– Place past filing documentation in chronological order behind the adjustment form• Each claim must have its own past filing documentation

– Address any gaps in filing limit documentation

– Use correct address; there is no separate address for filing limit adjustments

Note: Do not send claims to the Written Correspondence address

Paper claims



– HP is required to process 90 percent of noncheck-related adjustments within 30 days

– HP is required to process 100 percent of noncheck-related adjustments within 45 days

– Providers should contact HP Customer Service if an adjustment does not appear on an RA within 45 days of submission, plus mail time

Processing time


Where to Submit Adjustment Requests

– Forward noncheck-related and underpayment adjustment requests to:

HP AdjustmentsP.O. Box 7265Indianapolis, IN 46207-7265

– Forward check-related adjustments to:

HP RefundsP.O. Box 2303, Dept. 130Indianapolis, IN 46206-2303

–Return uncashed IHCP checks to:

HP Finance Unit950 N. Meridian, Suite 1150Indianapolis, IN 46204-4288


Where to Submit Adjustment Requests

– Send refunds for Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) claims to:

HP/CA-PRTF RefundsP.O. Box 7247Indianapolis, IN 46207

– Send Money Follows the Person (MFP) refunds to:

HP/MFP RefundsP.O. Box 7194Indianapolis, IN 46207


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

• Inquiry to HP Written Correspondence

Note: The above steps are not considered to be an appeal of a claim



– A formal administrative review must be filed within sixty days of notification of claim payment or denial from HP

– Send administrative review requests to the following address:

Administrative ReviewHP Written CorrespondenceP.O. Box 7263Indianapolis, 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



– 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

Refer to the IHCP Provider Manual, Chapter 10, Section 6 for more information

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written Correspondence

P. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

• View a current territory map and contact information online at indianamedicaid.com > Contact Us > Provider Relations Field Consultants

http://www.indianamedicaid.com/

http://provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

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