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Last Modified: 10/27/2019 Location: FL, PR, USVI Business: Part A

Adjustment and cancel claim data requirements FAQ

Q: What are the claim data requirements when adjusting or cancelling a claim?
A: The following information is required on adjustment and cancel claims. This is not an all-inclusive list, subsequently additional data elements may be required when adjusting or cancelling your claims.
Claims adjustment data requirements:

Data description
Requirement details
CMS form 1450 (UB-04)
Field Locator (FL)
DDE
MAP screen #
Page #
Type of bill (TOB)
3rd digit = 7 (TOB XX7)
FL 4
MAP1711
Page 01
Claim change reason code
or
condition code
D0 (zero) - Change in service dates
DI – Change in charges
D2 - Change in revenue codes, healthcare common procedure coding system (HCPCS), or health insurance prospective payment system (HIPPS) code-set
D3 - Change in revenue codes, healthcare common procedure coding system (HCPCS), or health insurance prospective payment system (HIPPS) code-set
D4 - Change in grouper input (Internal Classification of Diseases (ICD) diagnoses or procedure codes) -- PPS inpatient hospital
D7 - Change to make Medicare the secondary payer
D8 - Change to make Medicare the primary payer
D9 - Any other change -- remarks are required on the claim
E0 (zero) - Change in patient status
FL 18-28
MAP1711
Page 01
Document control number (DCN)
DCN is required for the claim being adjusted
FL 64
MAP1711
Page 01
Total charges
Delete and re-enter the recalculated total charges
FL 47
MAP1712
Page 02
Remarks
Remarks indicating the reason for the adjustment are required when condition code D9 is present
FL 80
MAP1714
Page 04
Select only one claim change reason code that best describes the reason for adjusting or cancelling the claim.
Direct Data Entry (DDE) users should delete the total charges line (0001) and rekey the line with the recalculated total charges and non-covered charges.
Cancel claims data requirements:

Data description
Requirement details
CMS form 1450 (UB-04)
Field Locator (FL)
DDE
MAP screen #
Page #
Type of Bill (TOB)
3rd digit = 8 (TOB XX8)
FL 4
MAP1711
Page 01
Claim change reason code
or
condition code
D5- Cancel-only to correct the patient Medicare number or provider identification number
D6 - Cancel-only to repay a duplicate payment or Office of Inspector General (OIG) overpayment -- includes cancellation of an outpatient bill containing services required to be included on the inpatient bill
FL 18-28
MAP1711
Page 01
Document control number (DCN)
DCN is required for the claim being cancelled
FL 64
MAP1711
Page 01
Remarks
It is recommended that remarks are included indicating the reason for cancelling the claim
FL 80
MAP1714
Page 04
Claims reopening data requirements:
Click here to review the guidelines for reopening claims.
Source(s): Centers for Medicare & Medicaid Services (CMS) internet-only manuals (IOM), publication 100-04,
Chapter 1 external pdf file, section 130; Chapter 34 external pdf file, sections 10.4 and 10.6.2;
Medicare Part A Direct Data Entry (DDE) Training Manual
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.