Adjustment Manual Introduction to Adjustments

Anthem Blue Cross and Blue Shield Anthem Training

09/08/06 rev 9/5/08 1-1 Mkolster
Unit 1 Introduction to Adjustments
Introduction
The purpose of the Adjustment Manual is to provide detailed information for
processing claims adjustments.
Objectives
After completion of this manual, the participant will be able to:
1. Define the two types of adjustments.
2. Compare different codes for provider adjustability.
3. Identify Disposition Field, Reason Field, Source Field, and Re-Receipt Date
Field.
4. Identify appropriate remittance and EOB dates.
5. Describe adjustment processing steps.
6. Describe manual check procedures.
Definition
An adjustment is used to modify or change the way a claim was originally processed.
Example:
the provider billed incorrectly
Anthem Blue Cross and Blue Shield did not pay the claim correctly (e.g.,
deductible taken when it should not have been)
Anthem Blue Cross and Blue Shield was not aware that the patient had other
insurance; therefore, the provider/policyholder received payment twice.
Adjustment Manual Introduction to Adjustments
Anthem Blue Cross and Blue Shield Anthem Training
09/08/06 rev 9/5/08 1-2 Mkolster
Adjustments may be statistical or may involve cash.
A statistical adjustment changes the information on the claim without changing the
payment amount. Once a claim has been processed to history, an additional
adjustment cannot be made.
A cash adjustment changes the amount paid.
Types of Adjustments
There are two types of adjustments:
1. Void - negates the original claim payment so the claim can be paid correctly.
2. Replacement - replaces incorrect information on the original claim with the correct
information.
Examples of when a voided adjustment would be done are:
paid wrong patient
paid wrong provider
paid in error/duplicate
overpaid (full refund received/required)
Examples of when a replacement adjustment would be done are:
claim rejected in error
claim overpaid (partial refund received/required)
claim paid incorrectly (wrong POS, TOS, procedure code, etc.)
claim overpaid (full refund received/required ONLY when reason is COB)
NOTE: Occasionally a facility/hospital will submit interim/subsequent bills as an
adjustment request. However, these are NOT true adjustments.
Adjustment Manual Introduction to Adjustments
Anthem Blue Cross and Blue Shield Anthem Training
09/08/06 rev 9/5/08 1-3 Mkolster
Interim/subsequent bills:
link new bills to a previously submitted claim
and
do not cause a change to the payment made on the original claim
When a request is received to process an interim/subsequent bill, it should be
keyed as an original claim using Bill Type 113 or 114.
Adjustment Manual Adjustment Information
Anthem Blue Cross and Blue Shield Anthem Training
09/08/06 rev. 06/04/2009 2-1 Performance Solutions
Unit 2 Adjustment Information
Adjustability of Providers
When a provider is adjustable, Anthem Blue Cross and Blue Shield can automatically
make a change to the way we originally paid a claim submitted by that provider. This
change will be reflected on the providers next remittance.
When a provider is nonadjustable, Anthem Blue Cross and Blue Shield cannot
automatically take money from or make additional payments to that provider.
However, some providers can only have additional money paid to them while others
can only have money retracted. The credit code will determine if we have to request
that the money be refunded or that a manual check be issued to pay the provider any
additional money.
NOTE: When the providers credit code does not allow us to do the type of
adjustment needed (e.g., a cash adjustment to automatically take money back or pay
more money), we need to do a statistical adjustment.
A statistical adjustment changes the information on a claim without changing the
payment amount. It does NOT retract money from the provider or generate a check
to the provider.
In cases where the provider owes us money, the statistical adjustment is done after
the money is returned.
A statistical adjustment can also be done to add something that has been left off
(i.e., Remarks).
NOTE: Once a claim has been processed to history, an additional adjustment cannot
be made.
Processing Adjustments in AIMS
Claims that cannot be updated in AIMS are claims other than professional (Type
P), claims other than Indemnity such as ITS Home ("6" in 5th digit of claim
number), HMO, claims with disposition Code 3 (retraction), or 4 (voided).
The fields which cannot be changed when adjusting electronic claims are the (1)
CMS Track Key and (2) LX numbers (CTD 3/14/04 Memo).