09/08/06 rev 9/5/08 1-1 Mkolster Unit 1 Introduction to Adjustments Introduction The purpose of the Adjustment Manual is to provide detailed information for processing claims adjustments. Objectives After completion of this manual, the participant will be able to: 1. Define the two types of adjustments. 2. Compare different codes for provider adjustability. 3. Identify Disposition Field, Reason Field, Source Field, and Re-Receipt Date Field. 4. Identify appropriate remittance and EOB dates. 5. Describe adjustment processing steps. 6. Describe manual check procedures. Definition An adjustment is used to modify or change the way a claim was originally processed. Example: the provider billed incorrectly Anthem Blue Cross and Blue Shield did not pay the claim correctly (e.g., deductible taken when it should not have been) Anthem Blue Cross and Blue Shield was not aware that the patient had other insurance; therefore, the provider/policyholder received payment twice. Adjustment Manual Introduction to Adjustments Anthem Blue Cross and Blue Shield Anthem Training 09/08/06 rev 9/5/08 1-2 Mkolster Adjustments may be statistical or may involve cash. A statistical adjustment changes the information on the claim without changing the payment amount. Once a claim has been processed to history, an additional adjustment cannot be made. A cash adjustment changes the amount paid. Types of Adjustments There are two types of adjustments: 1. Void - negates the original claim payment so the claim can be paid correctly. 2. Replacement - replaces incorrect information on the original claim with the correct information. Examples of when a voided adjustment would be done are: paid wrong patient paid wrong provider paid in error/duplicate overpaid (full refund received/required) Examples of when a replacement adjustment would be done are: claim rejected in error claim overpaid (partial refund received/required) claim paid incorrectly (wrong POS, TOS, procedure code, etc.) claim overpaid (full refund received/required ONLY when reason is COB) NOTE: Occasionally a facility/hospital will submit interim/subsequent bills as an adjustment request. However, these are NOT true adjustments. Adjustment Manual Introduction to Adjustments Anthem Blue Cross and Blue Shield Anthem Training 09/08/06 rev 9/5/08 1-3 Mkolster Interim/subsequent bills: link new bills to a previously submitted claim and do not cause a change to the payment made on the original claim When a request is received to process an interim/subsequent bill, it should be keyed as an original claim using Bill Type 113 or 114. Adjustment Manual Adjustment Information Anthem Blue Cross and Blue Shield Anthem Training 09/08/06 rev. 06/04/2009 2-1 Performance Solutions Unit 2 Adjustment Information Adjustability of Providers When a provider is adjustable, Anthem Blue Cross and Blue Shield can automatically make a change to the way we originally paid a claim submitted by that provider. This change will be reflected on the providers next remittance. When a provider is nonadjustable, Anthem Blue Cross and Blue Shield cannot automatically take money from or make additional payments to that provider. However, some providers can only have additional money paid to them while others can only have money retracted. The credit code will determine if we have to request that the money be refunded or that a manual check be issued to pay the provider any additional money. NOTE: When the providers credit code does not allow us to do the type of adjustment needed (e.g., a cash adjustment to automatically take money back or pay more money), we need to do a statistical adjustment. A statistical adjustment changes the information on a claim without changing the payment amount. It does NOT retract money from the provider or generate a check to the provider. In cases where the provider owes us money, the statistical adjustment is done after the money is returned. A statistical adjustment can also be done to add something that has been left off (i.e., Remarks). NOTE: Once a claim has been processed to history, an additional adjustment cannot be made. Processing Adjustments in AIMS Claims that cannot be updated in AIMS are claims other than professional (Type P), claims other than Indemnity such as ITS Home ("6" in 5th digit of claim number), HMO, claims with disposition Code 3 (retraction), or 4 (voided). The fields which cannot be changed when adjusting electronic claims are the (1) CMS Track Key and (2) LX numbers (CTD 3/14/04 Memo).