Tolerance Guidelines for Submitting Adjustment Requests

50.1 - Tolerance Guidelines for Submitting Adjustment Requests (Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014) When a bill is submitted and the hospital or the A/B MAC (A) discovers an error, the hospital submits an adjustment request using the ASC X12 837 institutional claim format or the Form CMS-1450, if the error is a change in the: • Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days; • Blood deductible; • Inpatient cash deductible of more than $1; • Servicing provider; • Discharge status in a PPS hospital; • Diagnosis or Procedures that impact the assigned DRG code; or • Outlier payment amount. The provider submits most adjustment requests as debits, using bill type XX7. Also, it submits a debit-only adjustment request to the A/B MAC (A) if the hospital previously submitted an interim bill for a PPS hospital stay or wishes to change the number of days in any inpatient stay. The A/B MAC (A) then submits the adjustment to CWF. An adjustment from the QIO for any of the above also requires a submission to CMS via CWF. If PPS is involved and the DRG has been changed as a result of medical review after an original bill has been forwarded to CMS, adjustment debit/credit bills are required. The corrected bill must be an exact duplicate of the original, except for any changed fields including diagnostic and procedure codes.