Filing adjustment form of Medicare Tips for Filing Adjustments

The following tips will assist in completing the adjustment form

• Complete only one adjustment request form per claim; a separate adjustment request form for each line item on a single claim is not necessary.

• Reference only one ICN per adjustment request form.

• If requesting a review of a previously denied adjustment, reference the original ICN and resubmit with all supporting documentation related to the adjustment. Do not reference the ICN for the denied adjustment.

• Include a copy of the appropriate RA with each adjustment request. If multiple RAs were involved in the claim payment process, include copies of each RA.

• Include a copy of the claim that is referenced on the adjustment request.
Note: This is not required for electronically submitted claims.

• When the adjustment request involves a corrected or revised claim, send both the original and revised claim. Do not obliterate previously paid details on the claim.

• Include pertinent information on a separate sheet of paper. Do not write information on the back of the adjustment form, RAs, etc.

• Ensure that all of the information submitted with the adjustment request is legible.

• Send only the medical records that pertain to the services rendered. If it is necessary to send records with other information included, identify the portion of the record that is significant to the adjustment request.

• Only the claim that pertains to the payment or denial in question should be submitted with the adjustment request. Do not submit any other claims with the adjustment request. Claims for service dates that have not been submitted should be filed on a new day claim, including late charges for codes not previously filed.

• When submitting an adjustment to Medicaid due to a Medicare-adjusted voucher, attach both the original voucher and the adjusted Medicare voucher. Reference the ICN of the original voucher.

• If requesting a review of a previous partial payment or a partial recoup adjustment, reference the ICN for the adjustment and resubmit with all supporting documentation related to the adjustment.

• Adjustments equal to or less than $1.00 will be denied.

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