Identifying Adjustments and Voids on the Remittance Voucher

Adjustments on the Remittance Voucher

Adjustment requests are printed on the remittance voucher as two different claim entries.

The incorrectly paid claim is listed exactly as it was when it was originally reported. The transaction control number (TCN) for this entry is not the same as the original claim, but is a system-assigned, unique “credit” TCN. The original incorrect payment is credited back to Medicaid’s account. A minus symbol ( - ) appears just to the right of the incorrectly paid amount. The adjusted request is printed directly following the original claim entry.

Incorrect claim information on the original now shows as corrected. The difference between these two entries is the “NET” amount on the remittance voucher.

An Adjustment Reason Code (ADJ-R) and the TCN of the claim being adjusted are listed following the two claim entries. Adjustment reason codes are defined in the summary section of the remittance voucher.

Voids on the RV 

Void requests are printed as one claim entry. The entire claim is displayed and the payment amount is returned to Medicaid. A minus symbol ( - ) appears next to the amount.

Adjustment or Void Reason Codes

An Adjustment Reason Code appears with each adjustment or void shown on the remittance voucher. These numeric codes are explained on the remittance voucher.

OVERPAYMENTS, Refund and OFFSET, Forward balance

An overpayment is defined as Medicare monies a provider or beneficiary received in excess of what is due and payable under the Medicare statute and regulations. Once determined that an overpayment has been made, the amount of overpayment is a debt owned to the United State government. It is important that providers/suppliers refund overpayment to NHIC as soon as they are detected. Below are examples of overpayments:

• Services billed in error

• Services were already paid

• Services were rendered to another patient

• Patient is not my patient

Providers/suppliers should report all refunds on the Overpayment Refund Form that can be found on our website at the following link:

http://www.medicarenhic.com/ne_prov/msp.shtml#ovp

Use of this form increases accuracy and efficiency. When indicating “other” as the reason for the refund, please provide an explanation as to why the refund is being made. Providers may include a check for the amount overpaid or request immediate offset from the next payment issued by NHIC. Healthcare providers or entities who are required to refund monies as part of a global settlement or fraud investigation with the Office of Inspector General must indicate a yes response on the refund form. Only those providers with a Corporate Integrity Agreement with the OIG should provide an affirmative response.

Include all pertinent information to the claim(s) on the form or on an attachment. Providers/suppliers may include a copy of the remittance advice highlighting the claim details.

Voluntary Refunds – Overpaid amounts voluntarily reported by providers should not contain language such as “payment in full” intending to absolve the payer of further obligation.

Contractor reviews will be conducted to confirm the amount overpaid or adjusted as indicated by the claims billing history on file. A “no” response on the refund form, under Medicare requested refund indicates the provider is voluntarily refunding the Medicare program.

Partial refunds – A partial refund may be requested when the provider wishes to return a portion of the amount paid by Medicare. Request for an offset of a future payment or refund check for the amount overpaid should be included. Partial refunds do not provide an amended provider remittance notice.

Providers/suppliers requiring a corrected invoice should request an immediate offset or return the amount paid for the entire claim with a request to void initial submission. A corrected claim may be filed once the initial claim is in a voided status.

Refund Checks – Providers/suppliers submitting a refund check should make checks payable to NHIC-Medicare. Refund checks should be forwarded to the address listed on the refund form or check the addresses on the website.

http://www.medicarenhic.com/ne_prov/msp.shtml#ovp

Offset - Overpayments may be recouped by “offset”. Medicare reduces future checks issued to a provider until the amount of overpayment is refunded. When Medicare identifies an overpayment, the offset process is initiated. Providers are sent a letter specifying information regarding the overpayment and are given 30 days to refund the overpaid amount. Overpayment notices contain an accounts receivable number (AR#) which identifies the transaction.

If the refund is not received from the provider within 30 days, a second notice is sent out for overpayments over $50.00, indicating that the overpayment is still outstanding and interest is now accruing. If the overpaid amount is not received upon 40 days of the initial notification,

NHIC will proceed with ‘offsetting’ money from payments to the provider until the overpaid amount is recovered. Interest on the total overpaid amount begins to accrue after the 29th day from the initial notice. Providers may avoid paying interest when choosing the offset method by initially requesting an “immediate offset”. When an immediate offset is requested, a notice is sent with the specific information regarding the offset, but the 40-day period is waived and offset is initiated immediately.Definition of a Medicare Overpayment

Medicare overpayment definition

A Medicare overpayment is a payment you receive in excess of amounts properly payable under Medicare statutes and regulations. Once Medicare identifies an overpayment, the overpayment amount becomes a debt you owe the Federal government. Federal law requires CMS try to recover all identified overpayments.

In Medicare, overpayments commonly occur due to:

™ Duplicate submission of the same service or claim;

™ Furnishing and billing for excessive or non-covered services;

™ Payment for excluded or medically-unnecessary services; or

™ Payment to the incorrect payee.

Overpayment Collection Process

When Medicare discovers an overpayment of $25 or more, the Medicare Administrative Contractor (MAC) initiates the overpayment recovery process by sending an initial demand letter requesting repayment. An Intent to Refer Letter (IRL) is mailed 60 days after the initial demand letter.

Demand Letter From Your MAC

Demand letters explain:

™ Medicare made an overpayment;

™ Interest begins to accrue if you do not repay the overpayment in full within 30 days;

™ Options to request immediate recoupment or an Extended Repayment Schedule (ERS); and

™ Rebuttal/appeal rights.

Your Options If You Receive a Demand Letter

You may choose from the following options when responding to an initial demand letter:

™ Make an immediate payment;

™ Request immediate recoupment;

™ Request the standard recoupment process (Automatic Offset/Withholding);

™ Request an ERS;

™ Submit a rebuttal; or

™ Request a redetermination to appeal the overpayment.

BCBS Overpayment Adjustment form

Use this form to request a recoupment from a future remittance or to send us a voluntary refund check for an overpayment we’ve made to you. This form can be used for any of the following plans or programs: Anthem Blue Cross and Blue Shield local plans (including plans sold on or off the Health Insurance Exchange), Federal Employee Program®, New England Health Plans, Medicare Advantage, BlueCard® and Taft Hartley. 

https://www.anthem.com/provider/noapplication/f4/s6/t0/pw_b123660.pdf?refer=ahpprovider

Adjustment Code Reference ID Forward Balance (FB)

• Used to reflect a balance being moved forward to a future remit or a balance that is brought forward from a prior remit.

• When a balance is moving forward to a future remit, the PLB FB contains the TRN02 (check or Electronic Funds Transfer [EFT] trace number) from the current 835 transaction.

• When a balance has been brought forward from a prior remit, the PLB FB contains the TRN02 (check or EFT trace number) that was the Reference ID in the prior remit.

• Use the dollar amount in the PLB to balance the 835 transaction.

• A negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice.

• The PLB FB is used to move a negative balance from a current 835 transaction into a future 835 transaction. Typically, this happens when we report an overpayment and there aren’t sufficient funds to recoup the entire overpayment amount.

• Forward Balance is tracked at the transaction level and is not claim-specific.

Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction. WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted

from the transaction. 

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund. We report a reversal to the original claim and a corrected claim in the 835. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the amount as a negative value in the PLB WO.

• If the reversal and corrected claim are not reported in the same 835 transaction, the 835 transaction that contains the reversal claim reports a negative value in the PLB WO. The 835 transaction that contains the corrected claim reports a positive value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• If a refund is not received within the timeframe requested in the letter, UnitedHealthcare recoups the money and reports this using the WO adjustment code. The 835 transaction that contains the overpayment recovery reduction will report a positive  value in the PLB WO.

Underpayments

• Used to balance the 835 transaction when the reversal and corrected claims are not reported in the same 835 transaction and prior payment is not being recouped. The 835 transaction that contains the reversal claim will report a negative value in the PLB WO. The 835 transaction that contains the corrected claim will report a positive value in the PLB WO.

• When the reversal and corrected claim are reported in the same 835 transaction, no PLB is reported. Provider refund check reporting

• When a refund check is received, the amount of the refund is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Voided checks

When a check is voided, the amount of the voided check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Refunds Process

There may be times when Blue Cross must request refunds of payments previously made to providers. When refunds are necessary, Blue Cross notifies the provider of the claim in question 30 days prior to any adjustment. 

The notification letter explains that Blue Cross will deduct the amount owed from future Payment Registers/Remittance Advices unless the provider contacts us in writing within 30 days.Recoveries and payments for omissions and underpayments shall be initiated within 15 months of the claim’s last date of payment or adjustment. Blue Cross and the participating provider agree to hold each other and the member harmless for underpayments or overpayments discovered after 15 months from the date of payment. 

If Blue Cross returns a claim or part of a claim for additional information, providers must resubmit it within 90 days or before the timely filing period expires, whichever is later. If Blue Cross has made any omissions or underpayments, the Plan will make payment for such errors as soon as they are discovered or within 30 days of written notice from the participating provider regarding the error.

We make every effort to pay claims in a timely manner; however, when a clean claim is not paid on time, we follow the late payment penalty guidelines outlined in House Bill 2052/Regulation 74. Providers automatically receive penalty payment for claims that are not processed in the time frames set forth by House Bill 2052/Regulation 74. The additional payment will almost always appear on the same  payment Register/Remittance Advice as the claims payment and can be identified by the status code “ST, Statutory Adjustment.”

Overpayments

In the event that Blue Cross has overpaid on a claim and we have not sent a request for the overpayment, please return it to us at the following address: 

Blue Cross and Blue Shield of Louisiana

Special Claims Review

P.O. Box 98029

Baton Rouge, LA 70898-9029

Please include the following information:

• Contract number

• Patient name

• Date of service

• Patient account number

• Reason for the overpayment

• Copy of remittance

Please Note: Facilities should actively work credit balances due to Blue Cross and return overpayments to Blue Cross. Refunds greater than $10,000 should be identified back to Blue Cross within 120 days from the occurrence date. This should be done even when credit balance recovery vendors are assisting with this process. Failure to do so will result in the facility being responsible for the fees incurred for the recovery.