Processing CMS-838 Claims Adjustments

10.1.3 - Processing CMS-838 Claims Adjustments (Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. A. The FI shall review the reported credit balances to ensure that the claims were paid by Medicare and the amounts listed appear to be appropriate. • The FI shall accept electronic or hard copy adjustment bills for repayment of Medicare credit balances from providers. • Based on the FI’s review of the credit balance, the FI should decide to do an adjustment or perform a canceled claim in FISS/HIGLAS to recoup the monies owed. For example: 1. Canceling-out the claim if the claim is entirely incorrect, a duplicate payment, a wrong Medicare beneficiary identifier, or if the Medicare credit balance resulted from an outpatient claim; or 2. Establish a claims adjustment if part of the claim needs modification and the remainder of the claim is correct; or 3. Perform a claims recoupment by withholding claim amounts from future Medicare claims. These withheld amounts are to be included in remittance advices to providers. B. Establish and maintain control of all adjustments and adjustment bills from the time you receive them.