CMS 1500 claim adjustments

Quick reference guide

What is a claim adjustment?

• A claim adjustment is a correction to a previously adjudicated and finalized claim
• Adjustments are identified by a frequency code that is added as a third position to the place of service

DDE specific information

Providers have two options:

• Select CMS 1500 online claim Form located on our provider portal . The adjustment is entered like a claim but includes required additions/deletions. Click on “Is this Claim an Adjustment” link (screen two), complete the claim frequency code, and supply the original aim information as appropriate.
• Select claim status inquiry to adjust claims. If the claim is located, the claim information auto populates in the claim entry application.

ANSI 837 specific information

• Frequency code is reported in the CLM05-3 of the 2300 loop
• Payer is reported in NM103-5 segment Loop 2010BC
• Original claim number is reported in the REF segment 2300 loop. If a vendor or clearinghouse is used, contact them for instructions on where to place the original claim number.

Provider responsibilities

• Submit the original claim number and frequency code adjustment indicator.
• Include remarks explaining the reason for requesting the correction.
• Submit corrections in a timely manner. Claim corrections submitted beyond timely submission requirements will be denied as provider liability. Providers must hold members harmless and may not bill the member.
• Adjustments may only be submitted once the original, or subsequent adjustments have been finalized.