Reprocess vs. Adjustment for Providers Utilizing DDE - Part A
WPS Medicare is clarifying the procedure on when you should submit an adjustment versus when the claim can be reprocessed.
If the entire claim was denied and currently has a "D B9997" status then you must submit an appeal for the denied claim.
If line item(s) in the claim has/have been denied with a 50000 range reason code(medical review was done on the line in question) and this is what you are adjusting, you must submit an appeal for the denied service.
If a claim has a line denial with a 50000 range reason code and you are trying to adjust other lines (not the line with the denial code) you should submit your request via DDE with your corrections and show the denied service as noncovered as they appear on the processed claim.
If the entire claim was rejected and currently has a "R B9997" status, you should submit your adjustment request via DDE.
If line item(s) in the claim has/have been rejected with a non-50000 range reason code and this is what you are adjusting, you should submit your adjustment request via DDE.
If a claim has a line reject with a non-50000 range reason code and you are trying to adjust other lines (not the line with the reject code) you should submit your adjustment request via DDE. Submit the adjustment request with your corrections and show the rejected service as non-covered as they appear on the processed claim.
If the entire claim was rejected and currently has a "R B9997" status and has an "X" in the tape to tape field, you should submit a new claim for processing. This situation does not require an adjustment.
*Note: In DDE, on page two of the claim, PF11 twice to see the tape-to-tape field.
You can find this information in your DDE manual, pages 132 and 134.
Page Last Updated: Thursday, 13-Nov-2008 09:04:05 CST
