Monday, October 25, 2010

adjustment request, refund request on CMS 1500


If you have been paid, but paid incorrectly for a claim or received payment from a third party
after Medical Assistance has made payment, you must complete and submit an Adjustment
Request Form (DHMH 4518A) to correct the payment.

If an incorrect payment was due to a keying error made by Medical Assistance, or you billed the
incorrect number of units, you must complete an Adjustment Request Form following the directions on the back of the form.

When completing the Adjustment Form, do not bill only for remaining unpaid amounts or units,
bill for entire amount(s).

Example: You submitted and received payment for three units, but you should have billed for five units. Do not bill for the remaining two units; bill for the full five units.

Total Refunds – If you receive an incorrect payment, return the check issued by the Medical Assistance Program only when every claim payment listed on the remittance advice is incorrect, i.e., none of the recipients listed are your patients. When this occurs, return with a copy of the remittance advice and the check with a complete Adjustment Request Form to the address on the bottom of the form.

Partial Refunds – If you receive a remittance advice, which lists some correct payments and some incorrect payments do not return the Medical Assistance Program check. Deposit the check and file an Adjustment Request Form for each individual claim paid incorrectly.

NOTE: For overpayments or refunds, the provider may issue and submit one check to cover more than one Adjustment Request Form.

Before mailing Adjustment Request Forms, be sure to attach any supporting documentation such as remittance advices and CMS-1500 claim forms.

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