Determining to Resubmit
Contents
1. will be provided in articles publications and publication dates after 06 18 2009 and will be posted at www PalmettoGBA com anc or www PalmettoGBA com asc CMTS Palmetto GBA EAN ES for MEDICARE amp SEENCANT SERVILES PARTNERS IN EXCELLENCE2. As providers review their finalized Medicare claims processed paid rejected or denied he or she may determine that a change addition or correction needs to be made to a finalized claim Generally speaking this change addition or correction to the finalized claim can be accomplished in one of three ways e Resubmission of the original claim with the changes additions and or corrections included e Adjustment of the claim with the changes additions and or corrections included or e Appeal of the claim providing documentation to support the change addition or correction to the claim Therefore the first thing the provider must do is to determine which of these actions is appropriate for the particular finalized claim he or she are reviewing Determining to Resubmit Providers may resubmit a new revised original claim if the finalized claim being reviewed was not posted to Medicare history in the Common Working File CWF Since no historical record of the claim exists in CWF the provider is free to create one and therefore a new original claim can be submitted To determine if the finalized claim was posted to CWF follow these steps 1 Access the finalized claim in Fiscal Intermediary Shared System FISS Direct Data Entry DDE using the Claims Inquiry function 12 on the INQUIRY Menu 2 Goto Page 2 of the claim which displays the revenue line items and charges billed on the claim 3 The first function key selectio
3. n available at the bottom of Page 2 should be PF2 F2 Press PF2 F2 on your keyboard 4 Reviewing the page now displayed line item detail on the left toward the top is the TPE TO TPE tape to tape field If this field contains an X the finalized claim was NOT posted to CWF 5 If is present the claim must be re submitted as an original claim with the changes additions or corrections included Determining to Adjust Most finalized claims that are processed paid or rejected status location code P B9997 or R B9997 are posted to Medicare history in CWF If a historical record of a claim does exist an adjustment transaction must be processed to update the historical record To determine if your finalized claim should be adjusted follow these steps 1 Access the finalized claim in FISS DDE using the Claims Inquiry function 12 on the INQUIRY Menu 2 Confirm that the status location code equals P B9997 or R B9997 NOTE Claims in status location P B9996 or R B7516 CANNOT be adjusted Providers must wait until these claims progress to status locations P B9997 and R B9997 Go to Page 2 of the claim which displays the revenue line items and charges billed on the claim The first function key selection available at the bottom of Page 2 should be PF2 F2 Press PF2 F2 on your keyboard Reviewing the page now displayed line item detail on the left toward the top is the TPE TO TPE tape to tape field If this field contai
4. ns an X the finalized claim was NOT posted to CWF 6 Ifthe TPE TO TPE field is blank or contains any value other than X the claim is posted in CWF and you must adjust 7 While still on the line item detail page MAP171D scroll PF6 F6 through the line items to determine if there are any medically denied DENIAL REAS denial reason code is in the 5nnnn range line items 8 If there is a medically denied line item on the claim FISS may not allow the provider to complete the adjustment electronically reason code 30940 In this instance the provider should submit a hard copy adjustment using the Hard Copy Claim Adjustment Correction Request Form go to www PalmettoGBA com anc or www PalmettoGBA com asc or www PalmettoGBA com rhhi select Forms SN CMTS Palmetto GBA EAN ES for MEDICARE amp SEENCANT SERVILES PARTNERS IN EXCELLENCE Determining to Appeal lf a claim or a line item on a claim is medically denied status location D B9997 and the provider has medical evidence that he or she think should allow the denied service to be covered by Medicare an Appeal must be filed using the Redetermination Request Form go to www PalmettoGBA com anc or www PalmettoGBA com asc or www PalmettoGBA com rhhi select Resources then Forms To determine if your finalized claim should be appealed follow these steps Access the finalized claim in FISS DDE using the Claims Inquiry function 12 on the INQUIRY Menu C
5. onfirm that the status location code for the finalized claim equals D B9997 You must Appeal this claim If the claim status location equals P B9997 or R B9997 you must check for medically denied line items Go to Page 2 of the claim which displays the revenue line items and charges billed on the claim The first function key selection available at the bottom of Page 2 should be PF2 F2 Press PF2 F2 on your keyboard Scroll PF6 F6 through the line items to discern the medically denied DENIAL REAS denial reason code is in the 5nnnn range line item s 7 If there is medical evidence to support coverage of the medically denied line item s you must Appeal this line item s Oe oer oe Using these processes should assure that the appropriate action is taken to accomplish changes additions or corrections to your finalized claims Resources e Direct Data Entry DDE User s Manual www PalmettoGBA com anc or www PalmettoGBA com asc or www PalmettoGBA com rhhi select Publications then Manuals e Hard Copy Claim Adjustment Correction Request Form www PalmettoGBA com anc or www PalmettoGBA com asc or www PalmettoGBA com rhhi select Forms e Appeals www PalmettoGBA com anc or www PalmettoGBA com asc or www PalmettoGBA com rhhi select Resources then Forms Disclaimer The information provided in this job aid was current as of 06 18 2009 Any changes or new information superseding the information in this job aid
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