Adjustment/Void Workshop

1. Adjustment/Void Workshop Presented by Mina Reynaga & Kristen Brice Provider Field Representatives

2. Contact Xerox Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. • For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal: • https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm • Email: NMPRSupport@acs-inc.com

3. Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL • http://www.hsd.state.nm.us/mad/policymanual.html BILLING INSTRUCTIONS • http://www.hsd.state.nm.us/mad/billinginstructions.html REGISTERS AND SUPPLEMENTS: • http://www.hsd.state.nm.us/mad/registers/2012.html

4. Xerox Field Representative Provider Field Representative: • Mina Reynaga- (505) 246-9988 Ext. 8131233 • Kristen Brice-(505) 246-9988 Ext. 8131216 • E-mail: Erminia.reynaga@Xerox.com • E-mail: Kristen.brice@Xerox.com • Cc: NMPRSUPPORT@Xerox.com

5. When is it necessary to fill out an adjustment form for a claim?

6. Adjustments • Claims paid incorrectly must be adjusted. • DO NOT resubmit a denied claim with an adjustment sheet attached.

7. Adjustments • Adjustments will not be considered unless submitted on the adjustment request form with the following attached: • Copy of the remittance advice. • Corrected claim.

8. Adjustments – Filing Limit • Requests to adjust a claim must be submitted within 90 days from the date on the RA for the paid claim.

9. Completing an Adjustment/Void Form

10. Adjustment/Void Request Form

11. Medicaid Claim Adjustment • Always fill out the corrected claim (replacement claim) exactly as the claim was originally filed with the exception of the information being changed.

12. X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

13. What is a Transaction Control Number (TCN)? • The TCN is a unique number assigned to each and every claim. This number contains information about the claim and can be used to identify your claim when calling provider services 30825900085000001

14. What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= Credit 30832300085000001 The first digit indicates what the claim “media” is: 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim Batch number The last two digits of the year the claim was received The claim number within the batch. The numeric day of the year. This is the Julian Date - this represents the date the claim was received by ACS: this claim - the 323rd day of 2008, or November 18, 2008

15. WHY DO YOU WANT TO ADJUST THIS CLAIM? WRONG DATE OF SERVICE, WRONG AMOUNT OF UNITS, WRONG PROC CODE, FORGOT MODIFIER……. “LINE 2, PROCEDURE CODE INCORRECT. CHANGE TO 99432 – SEE CORRECTED ATTACHED CLAIM. X ALWAYS DATE FORM ALWAYS SIGN FORM

16. 05 15 08 05 15 08 11 282 00 1 99431 1234567890 11 125 00 1 05 15 08 05 15 08 99432 11 99238 93 00 1 05 15 08 05 15 08 FILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING. RENDERING PROVIDER’S NPI Optional Optional 500 00 X Provider Med Gp 505 333-4444 1234 Rocky Road Mountain View, NM 8888 Situational Required 1234567890 ZZ363LF0000X BILLING PROVIDER’S NPI Qualifier TAXONOMY

17. Adjustment – CMS-1500

18. Claim Detail • You can also attach this page with your Void\Adjustment Request form.

19. X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

20. WHY DO YOU WANT TO ADJUST THIS CLAIM? WRONG DATE OF SERVICE, WRONG AMOUNT OF UNITS, WRONG PROC CODE, FORGOT MODIFIER……. “LINE 2, REVENUE CODE 0250 HAD 4 UNITS. CHANGE TO 5 UNITS, $99.64 – SEE CORRECTED ATTACHED CLAIM. X ALWAYS DATE FORM ALWAYS SIGN FORM

21. Adjustment - UB-04 Provider Name Street City, State Zip Required if pay to is different than physical address. 111 05/15/2008 05/17/2008 Clara Client F 01 01/01/1931 05/15/2008 80 2 0170 051508 2 1,326 00 0250 051508 5 99 64 0301 051508 3 187 00 0302 051508 3 134 00

22. FILL OUT CLAIM EXACTLY AS IT WAS PREVIOUSLY FILLED OUT, WITH THE EXCEPTION OF THE CHANGES (ADJUSTMENTS) YOU WILL BE MAKING. 1 1 1746 64 0001 08031007 1234567890 MEDICAID NPI # CLARA CLIENT 123456789 431 9 1234567890 ALAN ATTENDING B3 332S00000X TAXONOMY QUALIFIER

23. Adjustment – UB-04

24. Adjustments – Filing Guidelines Recap • Complete Adjustment/Void form. • Fill out corrected claim (CMS1500, UB04, or ADA 2006). • Complete all information as it was on the claim previously submitted, with the exception of the changes being made. • Attach a copy of the page of the RA in which the claim paid incorrectly. • Mail to Xerox PO Box 27460 Albuquerque, NM 87125-7460, Attn: Claims Adjustment (keep a copy for your files).

25. Completing an Adjustment/Void Form

26. X ALWAYS FILL IN THE INFORMATION BOXES BELOW THIS INFORMATION IS FROM THE TCN THAT PAID INCORECTLY

27. CLAIM WAS BILLED INCORRECTLY PLEASE VOID CLAIM X ALWAYS DATE FORM ALWAYS SIGN FORM

28. RA for Void

29. Claim Detail • You can also attach this page with your Void\Adjustment Request form.

30. Adjustments – Filing Guidelines Recap • Complete Adjustment/Void form. • Fill out corrected claim (CMS1500, UB04, or ADA 2006). • Complete all information as it was on the claim previously submitted, with the exception of the changes being made.

31. Adjustments – Filing Guidelines Recap continued- • Attach a copy of the page of the RA in which the claim paid incorrectly. • Mail to Xerox PO Box 27460 Albuquerque, NM 87125-7460, Attn: Claims Adjustment (keep a copy for your files). • Do not send in a check with your void request.