CMS Pub. 100-04, ch. 1, § 130.1.2.3

The FI must perform the following additional edits and investigate adjustment requests the

provider submits:

• A full denial once the bill is paid, except to accomplish retraction of a duplicate

payment;

• Inpatient Hospital Only - A change in DRG based on a change in age or sex;

• A change in deductible;

• An adjustment request that changes a previously submitted QIO adjustment

request;

• An adjustment of a bill due to a change in utilization or spell data on another bill;

• A reopening to change a no-payment bill to a payment bill;

• A reopening to pay a previously denied line item;

• An adjustment request the provider initiates with a claim change reason code

equal to D7, with the Medicare payment amount equal to or greater that the

previously paid amount; or

• An adjustment request with a claim change reason code equal to E0, and the claim

is for an inpatient PPS hospital. The FI must investigate if the change is from

patient status 02, transferred to another acute care facility.