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

The Adjustment Invoice is used to change information on an approved claim. Follow the

instructions for the completion of the Health Insurance Claim Form, CMS-1500 (02-12),

except for the locator indicated below.

Locator 22 Medicaid Resubmission

Code - Enter the 4-digit code identifying the reason for the submission of the adjustment

invoice.

1023 Primary Carrier has made additional payment

1024 Primary Carrier has denied payment

1025 Accommodation charge correction

1026 Patient payment amount changed

1027 Correcting service periods

1028 Correcting procedure/service code

1029 Correcting diagnosis code

1030 Correcting charges

1031 Correcting units/visits/studies/procedures

1032 IC reconsideration of allowance, documented

1033 Correcting

admitting,

referring,

prescribing,

provider identification number

1053 Adjustment reason is in the Misc. Category

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 adjusted. Only one claim can be adjusted on each CMS-1500 (02-12)

submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim)

NOTE: ICNs can only be adjusted 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 adjusted 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 Street, Suite 1300

Richmond, VA 23219