Health Information Management

Timeframe to adjust a claim

APCs Insider, July 23, 2004

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QUESTION: How long does a hospital have to submit an adjustment claim to Medicare for an Outpatient Prospective Payment System (OPPS) claim that was incorrectly coded?

ANSWER: The Centers for Medicare & Medicaid Services (CMS) recently published an explanation on this very issue. Medicare Claims Processing Pub. 100-4, Chapter 3 Inpatient Hospital Billing, Section 50 Adjustment Bills, states that the timeframe for submitting an adjustment claim on a timely filed original claim falls under the "administrative finality rules." This means that until your hospital's cost report is finally settled for that year, the claim can be adjusted.

Realistically, the claim may have been sent to history on your fiscal intermediary's system and you may need to "reactivate" it in order to perform an online adjustment-but it is still possible to adjust OPPS claims back to the beginning of the program (August 2000) for most providers. Although the section of the manual states "Inpatient Hospital Billing," the adjustment claim reasons include HCPCS codes that are only valid on outpatient and Part B only claims that are covered by OPPS.

In the past, it was commonly assumed 18 months was the time allowed to resubmit a claim because that is the timeframe for timely filing of an initial claim. Until recently, CMS had not published anything with regard to claim resubmission timeframes. Note that open cost reports can stretch on for years until they are finally settled. To determine whether a cost report remains open, contact the hospital's reimbursement manager.

For more information, refer to this Special Edition Medlearn Matters article (SE0420) regarding MMA Section 937, "Correction of Minor Errors and Omissions Without Appeals" at

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