Credit Balance Report Related Adjustments or Cancelations

When submitting a claim adjustment for an individual credit balance, complete the field locators (FL) required on an adjustment UB-04 claim or electronic equivalent. This includes the:

  • Type of Bill (FL 4), with the third digit of a '7'
  • Condition Code (FL 18-28)
  • You must enter an explanation of the adjustment in the Remarks field (FL 80) i.e., Refund to Medicare
  • Adjustment Reason Code on (FISS Page 03) must be a 'CB' and
  • Document Control Number (FL 64) of the claim being adjusted

When submitting a claim cancelation for an individual credit balance, complete the field locators (FL) required on a cancelation UB-04 claim or electronic equivalent. This includes the:

  • Type of Bill (FL 4), with the third digit of a '8'
  • Condition Code (FL 18-28) 'D5' – cancel to correct provider/patient's Medicare ID # or 'D6' – cancel duplicate payment
  • You must enter an explanation of the cancelation in the Remarks field (FL 80) i.e., Refund to Medicare and
  • Document Control Number (FL 64) of the claim being canceled

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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