US · guidance
CMS Pub. 100-04, ch. 1, § 140.3
Verification Edit for Claims with OPPS Payments
Effective for claims received on or after October 1, 2012, FISS shall install a verification
edit for claims with OPPS payments that exceed a reimbursement amount greater than
submitted charges. The edit shall be applied to the following providers and bill types:
Provider Type Types of Bills
Hospitals 12X, 13X, 14X
Contractors shall suspend those claims receiving the verification edit for development
and contact providers to resolve billing errors. If the contractor determines that the
reimbursement is excessive and claim corrections are required, the contractor shall return
the claim to the provider. If the contractor determines that the billing is accurate and the
reimbursement is not excessive, the contractor shall override the FISS edit and submit the
claim to the Common Working File (CWF).
History
(Rev. 2463, Issued 05-04-12, Effective: 10-01-12, Implementation: 10-01-12)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
5626b5c77a5525cb67e245fde96e0aebe0cf84a65ebc78f02a94e775343c43aa
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