Wednesday, August 24, 2016

Reason code 30940, provider not permitted to adjust


Q: We are receiving a return to provider (RTP) reason code 30940, so what steps can we take to avoid this reason code?

A: You will receive this reason code when you attempt to adjust a partially or fully medically denied claim. You are not permitted to adjust claims that are medically approved or denied.

Prior to correcting any claim, it is recommended that you review each line item service billed to determine if it has been medically denied or approved.

When the claim is within the timely filing limit, and there is medically denied line item(s) present:

• Cancel the original claim using type of bill (TOB) XX8
• If for a simple change, billing issue or to add/delete line items
• You are not permitted to cancel claims using direct data entry (DDE). You must cancel the claim though other electronic means or a hard copy (CMS-1450 form [UB-04]).
• Resubmit a corrected claim once the canceled claim has finalized (should take approximately two days)
• Add comments/remarks to the claim, must include all changes made
When the claim is beyond the timely filing limit, and a medically denied line item(s) present:
• Do not cancel and resubmit the claim
• Request a claim reopening using TOB XXQ
• If for a simple change, or billing issue
• You are not permitted to submit TOB XXQ using hard copy claims (CMS-1450 form [UB-04]). You must request the claim reopening via electronic media claims (EMC) or DDE.

If original claim does not include medically denied/reviewed lines, DDE users can F9 claim to reprocess.

If you do not agree with the decision for the medically denied line(s) and are within the time limit, you may submit a first level of appeal-redetermination.

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