Adjustment/Void Workshop

Presented byMina Reynaga & Kristen BriceProvider Field Representatives

Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL.For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal:

• https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm

• Email: NMPRSupport@acs-inc.com

Contact Xerox

Important State Websites

STATE WEBSITE:PROGRAM POLICY MANUAL

• http://www.hsd.state.nm.us/mad/policymanual.html

BILLING INSTRUCTIONS• http://www.hsd.state.nm.us/mad/billinginstructions.html

REGISTERS AND SUPPLEMENTS:• http://www.hsd.state.nm.us/mad/registers/2012.html

Xerox Field Representative

Provider Field Representative: Mina Reynaga- (505) 246-9988 Ext. 8131233 Kristen Brice-(505) 246-9988 Ext. 8131216

• E-mail: Erminia.reynaga@Xerox.com• E-mail: Kristen.brice@Xerox.com

• Cc: NMPRSUPPORT@Xerox.com

4

When is it necessary to fill out an adjustment form for a claim?

6September 2009

• Claims paid incorrectly must be adjusted.

• DO NOT resubmit a denied claim with an adjustment sheet attached.

Adjustments

7September 2009

Adjustments will not be considered unless submitted on the adjustment request form with the following attached:

• Copy of the remittance advice.• Corrected claim.

Adjustments

8September 2009

Adjustments – Filing Limit

• Requests to adjust a claim must be submitted within 90 days from the date on the RA for the paid claim.

Completing an Adjustment/Void Form

10

Adjustment/Void Request Form

11September 2009

Medicaid Claim Adjustment

Always fill out the corrected claim (replacement claim) exactly as the claim was originally filed with the exception of the information being changed.

12September 2009

X

ALWAYS FILL IN THE INFORMATION BOXES BELOW

THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

13September 2009

What is a Transaction Control Number (TCN)?The TCN is a unique number assigned to each and every claim. This number contains information about the claim and can be used to identify your claim when calling provider services

30825900085000001

The first digit indicates what the claim “media” is:

2 = electronic crossover

3 = other electronic claim

4 = system generated claim or adjustment

8 = paper claim

The last two digits of the year the claim was received

The numeric day of the year.

This is the Julian Date - this represents the date the claim was received by ACS: this claim - the 323rd day of 2008, or November 18, 2008

Batch number

The claim number within the batch.

30832300085000001

What is a Transaction Control Number (TCN)?

14

The twelfth digit in an adjustment/ void TCN will either be:

1= Debit2= Credit

15

WHY DO YOU WANT TO ADJUST THIS CLAIM? WRONG DATE OF SERVICE, WRONG AMOUNT OF UNITS, WRONG PROC CODE, FORGOT MODIFIER…….

“LINE 2, PROCEDURE CODE INCORRECT. CHANGE TO 99432 – SEE CORRECTED ATTACHED CLAIM.

X

ALWAYS SIGN FORMALWAYS DATE FORM

16

05 15 08 05 15 08 99431 1282 00

500 00X

11

Optional Optional

RequiredSituational

Provider Med Gp 505 333-44441234 Rocky RoadMountain View, NM 8888

05 15 08 05 15 08 99432 1125 0011

05 15 08 05 15 08 99238 1 93 0011

1234567890

TAXONOMY

ZZ363LF0000X

BILLING PROVIDER’S NPI

1234567890

RENDERING PROVIDER’S NPIFILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING.

Qualifier

17

Adjustment – CMS-1500

18September 2009

Claim Detail You can also attach this page with your Void\Adjustment Request form.

19September 2009

X

ALWAYS FILL IN THE INFORMATION BOXES BELOW

THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

20September 2009

WHY DO YOU WANT TO ADJUST THIS CLAIM? WRONG DATE OF SERVICE, WRONG AMOUNT OF UNITS, WRONG PROC CODE, FORGOT MODIFIER…….

“LINE 2, REVENUE CODE 0250 HAD 4 UNITS. CHANGE TO 5 UNITS, $99.64 – SEE CORRECTED ATTACHED CLAIM.

X

ALWAYS SIGN FORMALWAYS DATE FORM

21September 2009

Provider Name Street City, State Zip 05/15/2008 05/17/2008

111

01/01/1931 F 05/15/2008 01

Clara Client

80 2

Required if pay to isdifferent than physicaladdress.

Adjustment - UB-04

0170 051508 2 1,326 000250 051508 5 99 640301 051508 3 187 000302 051508 3 134 00

22

1234567890

B3 332S00000X

MEDICAID

123456789

1 1 1746 64

NPI #

TAXONOMYQUALIFIER

0001 08031007

CLARA CLIENT

9431

1234567890ATTENDING ALAN

FILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING.

23September 2009

Adjustment – UB-04

24September 2009

Adjustments – Filing Guidelines Recap

• Complete Adjustment/Void form.

• Fill out corrected claim (CMS1500, UB04, or ADA 2006).

• Complete all information as it was on the claim previously submitted, with the exception of the changes being made.

• Attach a copy of the page of the RA in which the claim paid incorrectly.

• Mail to Xerox PO Box 27460 Albuquerque, NM 87125-7460, Attn: Claims Adjustment (keep a copy for your files).

Completing an Adjustment/Void Form

26September 2009

X

ALWAYS FILL IN THE INFORMATION BOXES BELOW

THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

27September 2009

CLAIM WAS BILLED INCORRECTLY

PLEASE VOID CLAIM

X

ALWAYS SIGN FORMALWAYS DATE FORM

28September 2009

RA for Void

29September 2009

Claim Detail You can also attach this page with your Void\Adjustment Request form.

30September 2009

Adjustments – Filing Guidelines Recap

• Complete Adjustment/Void form.

• Fill out corrected claim (CMS1500, UB04, or ADA 2006).

• Complete all information as it was on the claim previously submitted, with the exception of the changes being made.

31September 2009

Adjustments – Filing Guidelines Recap continued-

• Attach a copy of the page of the RA in which the claim paid incorrectly.

• Mail to Xerox PO Box 27460 Albuquerque, NM 87125-7460, Attn: Claims Adjustment (keep a copy for your files).

• Do not send in a check with your void request.