Tips for Filing Adjustments

The following tips will assist in completing the adjustment form

• Complete only one adjustment request form per claim; a separate adjustment request form for each line item on a single claim is not necessary.

• Reference only one ICN per adjustment request form.

• If requesting a review of a previously denied adjustment, reference the original ICN and resubmit with all supporting documentation related to the adjustment. Do not reference the ICN for the denied adjustment.

• Include a copy of the appropriate RA with each adjustment request. If multiple RAs were involved in the claim payment process, include copies of each RA.

• Include a copy of the claim that is referenced on the adjustment request.

Note: This is not required for electronically submitted claims.

• When the adjustment request involves a corrected or revised claim, send both the original and revised claim. Do not obliterate previously paid details on the claim.

• Include pertinent information on a separate sheet of paper. Do not write information on the back of the adjustment form, RAs, etc.

• Ensure that all of the information submitted with the adjustment request is legible.

• Send only the medical records that pertain to the services rendered. If it is necessary to send records with other information included, identify the portion of the record that is significant to the adjustment request.

• Only the claim that pertains to the payment or denial in question should be submitted with the adjustment request. Do not submit any other claims with the adjustment request. Claims for service dates that have not been submitted should be filed on a new day claim, including late charges for codes not previously filed.

• When submitting an adjustment to Medicaid due to a Medicare-adjusted voucher, attach both the original voucher and the adjusted Medicare voucher. Reference the ICN of the original voucher.

• If requesting a review of a previous partial payment or a partial recoup adjustment, reference the ICN for the adjustment and resubmit with all supporting documentation related to the adjustment.

• Adjustments equal to or less than $1.00 will be denied.

The most common mistakes that are made when filing adjustments are these:

• Incomplete or invalid MID information or ICNs

• Multiple ICNs on the same form

• Unspecified or too-general reason for the adjustment request

• Missing copy of the RA related to the request

• Missing reference to the original ICN, or use of a denied adjustment ICN

• A partial payment or partial recoupment number is not referenced as the original ICN

• Filing the adjustment after the 18-month time limit

Note: If an adjustment is not filed until the 17th month from the date of service, the original claim may no longer be available in the system for adjustment. Submit adjustments as soon as possible so they can be processed within the 18-month time limit.

• Missing required documentation (Medicare vouchers, medical records, operative records, etc).

• Referencing the NPI on the adjustment request

Note: This form requests the MPN in the blank specified for Provider Number.