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