Sunday, October 3, 2010

CMS BOX 22 Medicaid Resubmission Code, Original Ref. No.

For Adjustments:

When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) assigned to the paid claim. This ICN appears on the remittance advice on which the original claim was paid. Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction.

For Resubmittals:

When resubmitting a denied claim, enter an “R” followed by the 13-character ICN assigned to the denied claim. This ICN appears on the remittance advice on which the original claim was denied.
Please refer to Subchapter 5, Part 6, of your MassHealth provider  manual for detailed billing instructions on claim status and correction.

Medicaid Resubmission Code Situational. If filing an adjustment or void, enter an “A” for an adjustment or a “V” for a void as appropriate AND one of the appropriate reason codes for the adjustment or void in the “Code” portion of this field. Enter the internal control number from the paid claim line as it appears on the remittance advice in the “Original Ref. No.” portion of this field. Appropriate reason codes follow:

Adjustments 

01 = Third Party Liability Recovery
02 = Provider Correction
03 = Fiscal Agent Error
90 = State Office Use Only – Recovery
99 = Other

Voids 

10 = Claim Paid for Wrong Recipient
11 = Claim Paid for Wrong Provider
00 = Other

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