CMS Pub. 100-04, ch. 1, § 130.1

Adjustment requests are the most common mechanism for changing a previously

accepted bill. They are required to reflect the results of QIO medical review. CMS may

also require adjustments if it discovers that bills have been accepted and posted in error to

a particular record. Adjustments that only recoup or cancel a prior payment are “credits”

and must match the original in the following fields:

• Intermediary control number (ICN/DCN);

• Surname;

• Medicare beneficiary identifier

When a definite match cannot be made on the three fields above, the provider’s MAC

will use the fields below as needed. Note that for older claims, ICN/DCN probably will

not match.

• Date of birth;

• Admission Date for inpatient, (Date of First Service for outpatient) unless

changed by this adjustment requests; and

• From/thru dates for inpatient, (Date of First Service/Date of Last Service for

Outpatient), unless changed by this adjustment request.

Cancel-only adjustment requests are not acceptable, except in cases of incorrect provider

identification numbers and incorrect Medicare beneficiary identifier. The provider must

submit a corrected replacement bill (bill type xx1) to its MAC after submitting the

cancel-only request for the incorrect bill.

The provider must submit all other adjustment requests as debits only. It shows the

ICN/DCN of the bill to be adjusted as described above, with the bill type shown as xx7.

It submits adjustment requests to its MAC either electronically or on hard copy.

Electronic submission is preferred. The ICN/DCN of an associated claim shall only be

reported on adjustments. The MAC shall return to the provider any original claim

reporting information in this field.

The MAC must enter the following bill types that relate to the entity generating the

adjustment request:

xx7 Provider (debit)

xx8 Provider (cancel)

xxF Beneficiary

xxG CWF

xxH CMS

xxI MAC

xxM MSP

xxP QIO

xxJ Other

xxK OIG/GAO

The provider submits all adjustment requests as bill type xx7 or xx8. Since several

different sources can initiate an MSP adjustment (e.g., the provider, CWF, or the MAC),

the MSP designation, xxM, takes priority over any other source of an adjustment except

OIG/GAO. When the provider submits an MSP adjustment request, the MAC will

change the bill type to xxM. These priorities refer only to the designation of the source

of the adjustment. The difference between CWF generating the adjustment request and

CMS generating the adjustment request is: An adjustment request is CWF-generated if

the MAC receives a CWF unsolicited response, alert or a CMS-L1002.

The MAC prepares an adjustment if instructed by CMS CO or CMS RO to make a

change. Typically, such direction from CMS is to retroactively change payment for a

class or other group of bills. Occasionally, CMS will discover an error in the processing

of a single bill and direct the MAC to correct it.

If adjustments are rejected by CWF for additional corrections, they must be corrected and

resubmitted. Even if a letter from CMS requests the adjustment action, the MAC must

submit the adjustment request in its CWF record. If a rejected adjustment request is

determined to be unnecessary, the MAC stops the adjustment action upon receipt of

correction.

Where an adjustment request changes subsequent utilization, the MAC notes this and

processes adjustments to subsequent bills if it services the provider.