Adjustment/Void Workshop Presented by Mina Reynaga & Kristen Brice Provider Field Representatives

Call or 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: inc.com/nm/general/loadstatic.do?page=ContactUs.htm inc.com/nm/general/loadstatic.do?page=ContactUs.htm Contact Xerox

Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL BILLING INSTRUCTIONS REGISTERS AND SUPPLEMENTS:

Xerox Field Representative Provider Field Representative: Mina Reynaga- (505) Ext Kristen Brice-(505) Ext Cc: 4

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

September Claims paid incorrectly must be adjusted. DO NOT resubmit a denied claim with an adjustment sheet attached. Adjustments

September Adjustments will not be considered unless submitted on the adjustment request form with the following attached: Copy of the remittance advice. Corrected claim. Adjustments

September 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

September 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.

September X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

September 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

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 What is a Transaction Control Number (TCN)? 14 The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= 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 – SEE CORRECTED ATTACHED CLAIM. X ALWAYS SIGN FORM ALWAYS DATE FORM

X 11 Optional Required Situational Provider Med Gp Rocky Road Mountain View, NM TAXONOMY ZZ363LF0000X BILLING PROVIDER’S NPI RENDERING PROVIDER’S NPI FILL 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

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

September X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

September 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 FORM ALWAYS DATE FORM

September Provider Name Street City, State Zip 05/15/ /17/ /01/1931 F 05/15/ Clara Client 80 2 Required if pay to is different than physical address. Adjustment - UB ,

B3332S00000X MEDICAID NPI # TAXONOMY QUALIFIER CLARA CLIENT ATTENDING ALAN FILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING.

September Adjustment – UB-04

September 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 Albuquerque, NM , Attn: Claims Adjustment (keep a copy for your files).

Completing an Adjustment/Void Form

September X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

September CLAIM WAS BILLED INCORRECTLY PLEASE VOID CLAIM X ALWAYS SIGN FORM ALWAYS DATE FORM

September RA for Void

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

September 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.

September 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 Albuquerque, NM , Attn: Claims Adjustment (keep a copy for your files). Do not send in a check with your void request.