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Nurse Anesthetist and Anesthesiologist Assistant Services Handbook

Appendix 5

Adjustment Request Form Completion Instructions

Revised Instructions (PDF, 20 KB)

The Adjustment Request Form (PDF, 89 KB) is used to request an adjustment of a paid or partially paid claim. Providers may request an adjustment when claim information needs to be changed. After the changes are made to the original claim, the adjusted claim is processed according to Medicaid guidelines.

Providers cannot adjust a totally denied claim. A claim that was totally denied must be resubmitted through normal channels after the additional information has been supplied or the necessary correction has been made to the claim.

Questions about adjustments and other procedures or policies may be directed to Provider Services at (800) 947-9627 or (608) 221-9883.

The Adjustment Request Form is reviewed by Wisconsin Medicaid based on the information provided to the Medicaid fiscal agent. Be as specific as possible when describing how the original claim is to be changed. Complete the adjustment request as follows:

Step 1: Enter the following information from your Remittance and Status (R/S) Report:

1. Provider name.
2. Wisconsin Medicaid provider number to which the claim was paid (8 digits).
3. Date of the R/S Report showing the paid claim you are adjusting.
4. Claim number of the paid/allowed claim (15 digits).
5. Complete name of the Wisconsin Medicaid recipient for whom payment was received (Last, First, MI).
6. Recipient’s Wisconsin Medicaid ID number (10 digits).

Step 2: Add a detail(s).

If submitting an adjustment to add a detail(s) to a paid/allowed claim, enter the complete information you are requesting to be added to the claim in Elements 7 through 15.

Correct a detail(s).

If submitting an adjustment to correct a detail(s) on a paid/allowed claim, enter the information from the R/S Report in Elements 7 through 15. Enter the correct information in the comment area.

Step 3: Indicate reason for adjustment.

16. Check one of the following boxes indicating your reason for submitting the adjustment:

• Recoup entire MA payment. This would include claims billed in error or completely paid by another insurance carrier.
• Other insurance payment. Enter the amount paid by the other insurance carrier.
• Copay deducted in error. Indicate if the recipient was a nursing home resident on the date of service, or the correct number of covered service days, or if an emergency service was provided.
• Medicare reconsideration. Attach both the original and the new Explanation of Medicare Benefits (EOMB). (If the claim was paid as a straight Wisconsin Medicaid claim, submit an adjustment to recoup that claim. Then submit a new day claim with the EOMBs attached.)
• Correct detail. Use the R/S Report to complete elements 7 through 15 with information about the claim to be adjusted. Enter the correct information in the comment area.
• Other/comments. Add any clarifying information not included above. If there are extenuating circumstances, complicated or new procedures, indicate "For Consultant Review" and attach appropriate documentation such as a history and physical, operative report, or anesthesia report.

Step 4: Enter the following:

*17. Authorized signature.

*18. Date of signature. Use either the MM/DD/YY format or the MM/DD/YYYY format.

19. Indicate if a corrected claim form is attached. This is optional but may allow your adjustment to be processed more quickly and accurately.

* If the date or signature is missing on the Adjustment Request Form, the claim will be denied.

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Wisconsin Medicaid Handbook list
Wisconsin Department of Health and Family Services
Wisconsin Medicaid and BadgerCare