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Auxilary Aids & Services

For information about the availability of auxiliary aids and services, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

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Jurisdiction 11 Part A
Appeals, Adjustments and the D9 Claim Change Reason (Condition) Code and Cancelling a Claim

This job aid will help providers understand the difference between requesting an Appeal (Redetermination) and submitting adjustment claims. It will also assist in determining when to submit a Clerical Error Reopening Request Form and First request. The job aid will help you understand when to use the D9 condition code (also known as the claim change reason code for 'Any Other Change'). Lastly, Instructions are provided about who needs to cancel a claim. 

Determining to Appeal
Providers can appeal a claim or a claim line item that receives a full or partial medical denial. If a claim or claim line item is medically denied (status location = D B9997) and the provider has medical evidence that the service should be covered by Medicare, an appeal may be submitted by using the First Request: Redetermination Request Form. To access this form, go to the J11 Part A Forms section or the J11 HHH Forms section.

Determining to Adjust
Claims that are processed, paid, or rejected (status location code = P B9997 or R B9997) and are 'posted' to Medicare history in the Common Working File (CWF) can be adjusted. If a historical record of a claim exists in CWF, an adjustment transaction must be processed to update the historical record. These adjustments may be made through Direct Data Entry (DDE) or through a vendor’s software. Again, review the claim to see if the claim is denied or a line item is denied for medical necessity. If the claim was partially denied, (i.e., the claim contains a medically denied line), providers can make adjustments electronically to any line item that was not medically denied. Providers may key the adjustment in DDE with the appropriate condition code that describes the change on the claim. Once adjusted, the claim will go to an S (Suspense) status and location to be reviewed by the claims department before processing.

In some instances the Direct Data Entry (DDE) system will not allow the provider to make the adjustment to a line item that is not medically denied. In this instance the provider should submit a hard copy adjustment using the Clerical Error Reopening Request Form which is available at the forms links above for Part A or Home Health and Hospice.

When to Submit an Online Adjustment
Providers can submit an online adjustment using bill type XX7 to correct:

  • Number of inpatient days
  • Claims coding
  • Adding additional charges
  • Blood deductible
  • Servicing hospital
  • Inpatient cash deductible of more than $1
  • Diagnosis Related Group (DRG) code *
  • Discharge status in a Prospective Payment System (PPS) hospital
  • Outlier payment amount

*If an adjustment the hospital initiates results in a change to a higher weighted DRG, the Medicare contractor edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted. If it is, the Medicare contractor processes the claim for payment. If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the Medicare Contractor processes the claim for payment and forwards it to CWF.

When to Submit a Clerical Error Reopening Form
The Centers for Medicare & Medicaid Services (CMS) defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:

  • Mathematical or computational mistakes
  • Transposed procedure or diagnostic codes
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate
  • Incorrect data items, such as provider number, use of a modifier or date of service

Note: Clerical errors or minor errors are limited to errors in form and content. Omissions do not include failure to bill for certain items or services or the failure to include a diagnosis for medical necessity. A contractor shall not grant a reopening to add items or services that were not previously billed, with the exception of a few limited items that cannot be filed on a claim alone (e.g., G0369, G0370, G0371 and G0374). Third party payer errors do not constitute clerical errors.

Understanding When to Use the D9 Claim Change Reason (Condition) Code
The following chart provides information on claim change reason condition codes. Only one claim change reason code can be used on each claim being adjusted. If more than one claim change reason code is entered, the claim will reject by FISS requesting the provider to use the best code that describes why the claim is being adjusted. 
 

Code
Description 
Code
Description
D0
Changes to Service Dates 
D6 
Cancel only to repay a duplicate OIG payment
D1
Changes to Charges
D7
Change to Make Medicare Secondary Payer
D2 
Changes in Revenue Codes/HCPCS/HIPPS 
D8
Change to Make Medicare Primary Payer
D3
Second or Subsequent Interim PPS Bill 
D4
Changes in Grouper Codes
D5
Cancel to correct HICN or Provider ID 
D9 
Any Other Change
E0 (zero)
Change in patient Status   
 
 

Cancellation of a claim
You can only cancel a paid claim -- a claim cannot be cancelled unless it has been finalized and is reflected on the remittance advice. To cancel a claim, follow the guidelines below:

When in DDE, choose option 3 from the main menu, and then the appropriate selection for your type of bill on the next screen. The original paid claim will show with the DCN.

  • Use type of bill -- xx8 (The '8' tells the fiscal intermediary standard system (FISS) you are cancelling the originally submitted claim)
  • Condition code (use one of the following two condition codes):
    • D5 -- cancel to correct HICN or provider ID
    • D6 -- cancel only to repay a duplicate or OIG overpayment
  • Remarks -- add remarks telling us why you’re canceling the claim

NOTE: Providers cannot submit a redetermination request form (appeal) and submit to Palmetto GBA in order to cancel a claim. Claims can only be cancelled electronically.

 

References:

 

last updated on 03/27/2014
ver 1.0.51