Tuesday, August 30, 2011

Resolving an Incorrect Payment in EOB - Adjustment or void payment


A provider who receives an incorrect payment for a claim or receives payment from a third party after Medicaid has made payment is required to submit an adjustment or a void to correct the payment.

Adjustment An adjustment is needed if the correction to the payment would result in a partial refund or the claim was underpaid. Only paid claims can be adjusted.

Void A void is needed if the correction to the payment would result in a complete refund of the Medicaid payment to the fiscal agent.

All Claims Are Incorrect on the Remittance Voucher

If a provider receives a payment for claims that the provider did not submit, the provider should return the funds issued by the fiscal agent only when every claim payment listed on the remittance voucher was paid to the provider in error. For example, none of the recipients listed on the remittance voucher are the
provider’s patients. In this situation, return the remittance voucher and funds with a short note of explanation to:

ACS State Healthcare
P.O. Box 14597
Tallahassee, Florida 32314-4597

Partially Incorrect Claims on the Remittance Voucher

If the remittance voucher contains some correct payments and some incorrect payments, do not return the Medicaid check to the fiscal agent. Deposit the check and file a void request for each individual claim payment that should be completely refunded to Medicaid. File an adjustment request for each individual
claim payment that was partially incorrect.

Incorrectly Billed or Keyed Claims

An adjustment or void request will be processed as a replacement to the original, incorrectly paid claim. All claim items on the request must be correctly completed. An adjustment or void must be for the entire amount not just for remaining unpaid amounts or units.

For example, if a provider billed for and received payment for 3 units of a procedure and should have billed for 5 units, the provider must submit a claim for the full 5 units as an adjustment.

Adjustments for Keying Errors

If an incorrect payment was the result of a keying error, the provider can either:

·  Call the fiscal agent at 800-289-7799 (in Florida)
or 800-955-7799 (outside Florida) and request the claim be reprocessed; or

·  Photocopy the claim, circle the item that was incorrectly keyed, sign and
date the form, and resubmit it to the fiscal agent.

The provider should check to be sure that a keying error caused the incorrect payment. In some cases, the claim payment must be reduced due to service limitations. If the maximum allowable amount according to the fee schedule was not paid, the remittance voucher in the adjustment reason code column will specify the reason. All adjustment reason codes are translated at the end of the remittance voucher just after the summary section.

Third Party Recovery After Medicaid’s Payment

If a provider receives payment from a third party after Medicaid paid the claim, the provider must submit an adjustment or void request.

·  A void is required if another carrier’s payment was equal to or higher than Medicaid’s maximum allowable amount.
·  An adjustment is required if the other carrier’s payment was less than the Medicaid maximum allowable amount.

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