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

2. 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 https://nmmedicaid.acs- inc.com/nm/general/loadstatic.do?page=ContactUs.htm Email: NMPRSupport@acs-inc.comNMPRSupport@acs-inc.com Contact Xerox

3. 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

4. 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.comErminia.reynaga@Xerox.com E-mail: Kristen.brice@Xerox.comKristen.brice@Xerox.com Cc: NMPRSUPPORT@Xerox.comNMPRSUPPORT@Xerox.com 4

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

6. September 2009 6 Claims paid incorrectly must be adjusted. DO NOT resubmit a denied claim with an adjustment sheet attached. Adjustments

7. September 2009 7 Adjustments will not be considered unless submitted on the adjustment request form with the following attached: Copy of the remittance advice. Corrected claim. Adjustments

8. September 2009 8 Adjustments – Filing Limit Requests to adjust a claim must be submitted within 90 days from the date on the RA for the paid claim.

9. Completing an Adjustment/Void Form

10. 10 Adjustment/Void Request Form

11. September 2009 11 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.

12. September 2009 12 X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

13. September 2009 13 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

14. 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= Debit 2= Credit

15. 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 FORM ALWAYS DATE FORM

16. 16 05 15 08 99431 1282 00 500 00 X 11 Optional Required Situational Provider Med Gp 505 333-4444 1234 Rocky Road Mountain View, NM 8888 05 15 08 99432 1125 0011 05 15 08 992381 93 0011 1234567890 TAXONOMY ZZ363LF0000X BILLING PROVIDER’S NPI 1234567890 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. 17 Adjustment – CMS-1500

18. September 2009 18 Claim Detail You can also attach this page with your Void\Adjustment Request form.

19. September 2009 19 X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

20. September 2009 20 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

21. September 2009 21 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 is different than physical address. Adjustment - UB-04 0170 051508 2 1,326 00 0250 051508 5 99 64 0301 051508 3 187 00 0302 051508 3 134 00

22. 22 1234567890 B3332S00000X MEDICAID 123456789 1 1 1746 64 NPI # TAXONOMY QUALIFIER 000108031007 CLARA CLIENT 9 431 1234567890 ATTENDING ALAN FILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING.

23. September 2009 23 Adjustment – UB-04

24. September 2009 24 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).

25. Completing an Adjustment/Void Form

26. September 2009 26 X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

27. September 2009 27 CLAIM WAS BILLED INCORRECTLY PLEASE VOID CLAIM X ALWAYS SIGN FORM ALWAYS DATE FORM

28. September 2009 28 RA for Void

29. September 2009 29 Claim Detail You can also attach this page with your Void\Adjustment Request form.

30. September 2009 30 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.

31. September 2009 31 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.