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Adjustment of Claims with Automated Medical Review Denials

National Government Services would like to provide clarification to providers receiving automatic denials on claims. In certain circumstances it may be necessary to correct a billing issue on a claim which has received a medical review automated denial. Providers cannot remove or place the medical review denied line in the covered field, but may adjust units or charges of the noncovered line as long as it remains in the noncovered field. The provider may also make changes to other items on the claim as long as the medical review automated denied line remains in the noncovered field.


Adjustment Request Scenarios

  1. Remove paid lines
  2. Remove paid and denied lines (only the paid lines may be removed)
  3. Add charges
  4. Correct primary payer information
  5. Combine charges on the same type of bill or change of the date of service (retraction of payment for one day and bill the entire month)
  6. Refund Medicare payment due to reimbursement from other insurance
  7. Adjust paid lines
  8. Change discharge status
  9. Adjust units or charges on noncovered lines (must remain noncovered)

Cancel Scenarios

  1. Cancel to change type of bill (i.e., submitted 14X but should have submitted 13X)
  2. Cancel due to outpatient overlap of a skilled nursing facility benefit period
  3. Cancel due to outpatient within 72 hours of an inpatient stay
  4. Cancel to correct the Health Insurance Claim number (HICN)

Revisions have been made to the narratives for reason codes 30940 and 30941 to provide instruction of when and how providers can submit an adjustment to change or cancel a claim. Specific remarks required for electronic submission of adjustment requests are included in the descriptions for these reason codes. It is important for providers to include the specific information in the remarks area as well as indicating that the noncovered charges are not being disputed. The auto denied lines need to be shown on the adjustment as noncovered.

Adjustment of claims which are totally noncovered must be submitted in a hard-copy format. When submitting a hard-copy UB-04, providers should not attach any correspondence to the pink and white copy such as a redetermination request or a letter requesting the change be made to the claim. Only the hard-copy UB-04 showing all changes, auto denied lines as noncovered and specific remarks should be sent.

If an electronic adjustment that was submitted to correct something on the claim when the auto denied line is not disputed is returned to the provider, review the reason code narrative carefully to determine how to correctly submit the adjustment. It is not necessary to submit a redetermination request if the noncovered line is not being disputed.

Adjustment of Claims with Automated Medical Review Denials
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