How to File Adjustment claim request


Filing Adjustments for a Medicare/Medicaid Claim 

When a provider has filed a claim with Medicare, Medicare reimburses the claim, then the claim becomes a “crossover” to Medicaid for consideration of payment of the Medicare deductible and/or co-insurance/co-payment.

If, at a later date, it is determined that Medicare has overpaid or underpaid, the provider should rebill Medicare for a corrected payment. These claims may “crossover” from Medicare to Medicaid, but cannot be automatically processed by Medicaid (as the electronic crossover claim appears to be a duplicate claim, and therefore must be denied by Medicaid).

In order for the provider to receive an adjustment, it is necessary for the provider to file a hard copy adjustment claim (Unisys Form 213) with Medicaid. These should be sent to Unisys, Attention: Crossover Adjustments, P.O. Box 91023, Baton Rouge, LA 70821, and should have a copy of the most recent Medicare explanation of benefits and the original explanation of benefits attached. In addition, the provider should write “2X7” at the top of the adjustment/void form to indicate the adjustment is for a Medicare/Medicaid claim.


Instructions for Completing the 213 Adjustment/Void form

1. REQUIRED ADJ/VOID—Check the appropriate block

2. REQUIRED Patient’s Name

a. Adjust—Print the name exactly as it appears on the original claim if not adjusting this information

b. Void—Print the name exactly as it appears on the original claim

3. Patient’s Date of Birth

a. Adjust—Print the date exactly as it appears on the original claim if not adjusting this information

b. Void—Print the name exactly as it appears on the original claim

4. REQUIRED Medicaid ID Number—Enter the 13 digit recipient ID number

5. Patient’s Address and Telephone Number

a. Adjust—Print the address exactly as it appears on the original claim

b. Void—Print the address exactly as it appears on the original claim

6. Patient’s Sex

a. Adjust—Print this information exactly as it appears on the original claim if not adjusting this information

b. Void—Print this information exactly as it appears on the original claim

7. Insured’s Name— Leave blank

8. Patient’s Relationship to Insured—Leave blank

9. Insured’s Group No.—Complete if appropriate or blank

10. Other Health Insurance Coverage—Complete with 6-digit TPL carrier code if appropriate or leave blank

11. Was Condition Related to—Leave blank

12. Insured’s Address—Leave blank

13. Date of—Leave blank

14. Date First Consulted You for This Condition—Leave blank

15. Has Patient Ever had Same or Similar Symptoms—Leave blank

16. Date Patient Able to Return to Work—Leave blank

17. Dates of Total Disability-Dates of Partial Disability—Leave blank 2007 Louisiana Medicaid Professional Services Provider
Training 123

18. Name of Referring Physician or Other Source—Leave this space blank

18a. Referring ID Number—Enter The CommunityCARE authorization number if applicable

or leave blank.

19. For Services Related to Hospitalization Give Hospitalization Dates—Leave blank

20. Name and Address of Facility Where Services Rendered (if other than home or office)—

Leave blank

21. Was Laboratory Work Performed Outside of Office—Leave blank

22. REQUIRED Diagnosis of Nature of Illness

a. Adjust—Print the information exactly as it appears on the original claim if not

adjusting the information

b. Void—Print the information exactly as it appears on the original claim

23. Attending Number—Enter the attending number submitted on original claim, if any, or

leave this space blank

24. Prior Authorization #—Enter the PA number if applicable or leave blank

25. REQUIRED A through F

a. Adjust—Print the information exactly as it appears on the original claim if not

adjusting the information

b. Void—Print the information exactly as it appears on the original claim

26. REQUIRED Control Number—Print the correct Control Number as shown on the

remittance advice

27. REQUIRED Date of remittance advice that Listed Claim was Paid—Enter MM DD YY

from RA form

28. REQUIRED Reasons for Adjustment—Check the appropriate box if applicable, and

write a brief narrative that describes why this adjustment is necessary

29. REQUIRED Reasons for Void—Check the appropriate box if applicable, and write a

brief narrative that describes why this void is necessary

30. REQUIRED Signature of Physician or Supplier—All Adjustment/Void forms must be

signed

31. REQUIRED Physician’s or Supplier’s Name, Address, Zip Code and Telephone Number—Enter the requested information appropriately plus the seven (7) digit Medicaid provider number. The form will be returned if this information is not entered.

32. Patient’s Account Number—Enter the patient’s provider-assigned account number. REQUIRED items must be completed or form will be returned.

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