Voiding Claims on a CMS 1500 Paper Claim Form - Medicaid

When requesting a void, the provider must:

Resubmit a photocopy of the original claim or a new claim form;

Enter the items listed below; 
Initial and date the form if it is a photocopy, or sign and date the form if it is a new form; and

Mail the void request to the fiscal agent for processing at:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

Billing instruction

BOX # 1 Void Enter a ―V‖ for a void.

Internal Control Number -  Enter the most recently paid Internal Control Number (ICN) for the incorrectly paid claim. For a legacy claim that the prior Medicaid fiscal agent processed that has a 17-digit Transaction Control Number (TCN), enter the TCN.

Enter the ICN or TCN assigned to the paid claim in the upper left corner, above the top line of the form. Be sure to enter all the digits correctly. Enter the most recent ICN or TCN for the claim.

1a  Recipient’s Medicaid ID No.  -  If using a new claim form, enter the recipient‘s ten-digit Medicaid ID Number

2 Recipient’s Name - If using a new claim form, enter the recipient‘s last name, first name and middle initial exactly as it appears on the gold plastic Medicaid ID Card or other proof of eligibility

31 Authorized Signature and Title - If using a new claim form, it must be signed. A photocopied form must be initialed and dated. The signature must be that of the provider, its employees or authorized billing agent.

31 Billing Date If using a new claim form, it must be dated. Use the month, day, year format: MM/DD/YY. Example: 08/21/06 for August 21, 2006

33 Biller Provider Info & PH #  If using a new claim form, enter the billing provider‘s name, address, zip code plus 4, and telephone number.

33a NPI - If entering the pay to provider‘s NPI, enter it in this field. If the rendering provider‘s NPI is mapped to a taxonomy code that is needed to identify the provider in the Florida Medicaid claims processing system, the rendering provider must enter qualifier code ZZ and the taxonomy code in item 33b. If not entering the NPI, leave blank

33b Other ID # If entering the pay to provider‘s Medicaid provider number, enter it in this item preceded by the qualifier code 1D (qualifier code 1D stands for Medicaid provider number).
If entering the pay to provider‘s NPI in item 33a, and if the NPI is mapped to a taxonomy code that is needed to identify the provider in the Florida Medicaid claims processing system, enter qualifier code ZZ and the taxonomy code.
If the provider is a group provider, the group number must be entered and the individual treating provider number must be entered in item 24 J for each claim line billed

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