Last Modified: 9/22/2017 Location: FL, PR, USVI Business: Part A
Identifying medically reviewed adjudicated claims
Providers may not make adjustments (e.g., add services, change units) to claims that have been medically reviewed and denied. When adjustments are attempted on these claims, providers will receive reason code 30940 (A provider is not permitted to adjust a partially or fully medically denied claim.). This reason code is triggered because the initial claim had at least one service that was medically reviewed.
Listed below are the processes you should follow to determine if a claim was medically reviewed and to make changes.
Identifying medically reviewed claims
The term “medically reviewed” has several meanings. It could mean the claim was medically reviewed and denied. It could also mean the claim was medically reviewed, but the claim was paid. These claims are reviewed based on medical policy and are either paid in full, partially paid, or totally denied.
Direct data entry (DDE) users
DDE users can determine if a claim was medically reviewed by looking on claim Page 2 (MAP1712). Providers should look for the following on MAP171D:
• A “5XXXX” reason code in the FMR field;
• A number in the NCD RESP field; or
• An NCD number in the NCD field.
To locate the institutional claim inquiry screen for line items that may be partially or fully denied, go to Page 2 and press F2 or F10, this will take you to MAP171D. The MED REV RSNS field shows the reason code associated with the line items.
Refer to the DDE manual for specifics related to the fields mentioned.
Canceling and resubmitting claims that were medically reviewed and denied
If changes need to be made to a claim that was medically reviewed and denied, providers must cancel the initial claim and then submit a new corrected claim. This ensures that all changes on the new claim go through the appropriate medical policy review again. Only lines that are medically reviewed and denied are appealable.
Cancel the original claim, indicating type of bill xx8. Once the cancelation has finalized (usually in two days), resubmit the corrected claim. When you resubmit the corrected claim, make sure you’re correcting any lines you were trying to adjust. Be sure to include remarks as to the reason you are canceling the claim (e.g., canceling due to billing error).
• Make sure to complete the cancelation and claim resubmission within one year from the date of service on the claim.
DDE providers: If you submit claims via DDE, you cannot cancel the claim. You must resubmit the claim through alternate electronic means or on a hard copy UB-04 claim form, indicating type of bill xx8.
Providers cannot submit appeals for additional charges on medically reviewed claims.
Source: Provider Outreach and Education
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