[Provider] Clarification for Denied and Suspended Adjustments

[Provider Notification]

ATTENTION:  All MaineCare Providers Submitting Adjustments to MeCMS

 

Clarification of the MeCMS adjustment functionality for denied and
suspended adjustments follows.

 

Clarification of Adjustment Functionality within MeCMS for Denied
Adjustment

 

If an adjustment claim is denied for an adjustment edit (an error that
will cause the adjustment action to fail or be denied), the credit
portion of the adjustment will not be created in the system. The status
of the original claim will revert back to its original status of
"Paid/RA Generated", "Paid/CDI", or "Adjudicated/RA Generated" in MeCMS.


 

Adjustment edits are:

*         Missing Claim Detail

*         Line Level Adjustment or Void To Room & Board, Cost of Care,
Spend Down Bill Prov Type=31

*         Former TCN Missing or Not on File

*         Former TCN Status Invalid

*         Former TCN Billing Provider Mismatch

*         Former TCN Member ID Mismatch

 

How this will appear on the Remittance Advice (RA): 

An adjustment denied for one of the above edits will appear on the
Remittance Advice (RA) and the RA will reflect ONLY the denied
adjustment, i.e., there will be a denied adjustment entry under
"Category: Adj-Deny" with no associated "Credit" on the RA.

 

What the affect is:

The original claim (the claim you are trying to adjust) will not be
affected and the status in MeCMS for the original claim will revert back
to "Paid/RA Generated". This claim remains in its original state and the
original claim can be adjusted or voided in the future.

 

Provider action:

Provider can submit a new adjustment to adjust the original claim or
void the original claim and re-bill.

 

However, if an adjustment claim is denied for edits OTHER than those
mentioned above, a credit claim will be created in the system for both
header and line level adjustments.

 

How this will appear on the Remittance Advice (RA): 

An adjustment denied for any other edit (that would have caused the
original claim to deny had it been submitted today) will appear on the
RA under "Category: Adj-Deny" and the RA will reflect BOTH the denied
adjustment AND an associated "Credit" entry under "Category:
Adjustment".

 

What the affect is:

The original claim (the claim you are trying to adjust) payment will be
taken back and the status in MeCMS will change to "Adjusted/RA
Generated". This claim has effectively been "voided" and is available
for re-bill to correct whatever billing error caused the claim to deny
during the "adjustment".

 

Provider action:

Provider can re-bill the claim.

 

 

Clarification of Adjustment Functionality within MeCMS for Suspended
Adjustment

 

If an adjustment claim is suspended (in MeCMS) for any edit (an error
that will cause the adjustment action to suspend for review), the credit
portion and the payment portion of the adjustment will not process until
the suspension is resolved by a claims evaluator. Once the suspension is
resolved, the adjustment will both process and adjust the claim (at
which time the credit and payment portion of the adjustment will appear
on the RA together under "Category: Adjustment"), OR the adjustment will
deny and the process flow will be as described above for a denied
adjustment. 

 

 

This is a one-way communication.  Please do not respond to this message.

 

 

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