Va. DMAS Hospice Provider Manual ch. V, Instructions For The Completion Of The Health Insurance Claim Form CMS-1500 (02-12), As A Void Invoice

The Void Invoice is used to void a paid claim. Follow the instructions for the completion

of the Health Insurance Claim Form, CMS-1500 (08-05), except for the locator indicated

below.

Locator 22 Medicaid Resubmission

Code - Enter the 4-digit code identifying the reason for the submission of the void invoice.

1042 Original claim has multiple incorrect items

1044 Wrong provider identification number

1045 Wrong member eligibility number

1046 Primary carrier has paid DMAS maximum allowance

1047 Duplicate payment was made

1048 Primary carrier has paid full charge

1051 Member not my patient

1052 Miscellaneous

1060 Other insurance is available

Original Reference Number/ICN - Enter the claim reference number/ICN of the paid

claim. This number may be obtained from the remittance voucher and is required to

identify the claim to be voided. Only one claim can be voided on each CMS-1500 (02-12)

submitted as a Void Invoice. (Each line under Locator 24 is one claim).

NOTE: ICNs can only be voided through the MES Provider Portal up to three years from

the date the claim was paid. After three years, ICNs are purged from the MES and can

no longer be voided through the system. If an ICN is purged from the system, the provider

must send a refund check made payable to DMAS and include the following information:

• A cover letter on the provider’s letterhead which includes the current address,

contact name and phone number.

• An explanation about the refund.

• A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to:

Department of Medical Assistance Services

Attn: Fiscal & Procurement Division, Cashier 600 East Broad St. Suite 1300

Richmond, VA 23219