If a provider fails to include a particular item or service on its initial bill, an adjustment
bill(s) to include such an item(s) or service(s) is not permitted after the expiration of the
time limitation for filing a claim. However, to the extent that an adjustment bill otherwise
corrects or supplements information previously submitted on a timely claim about
specified services or items furnished to a specified individual, it is subject to the rules
governing administrative finality, rather than the time limitation for filing.
Under prospective payment, adjustment requests are required from the hospital where
errors occur in diagnoses and procedure coding that change the DRG, or where the
deductible or utilization is affected. A hospital is allowed 60 days from the date of the
A/B MAC (A) payment notice for adjustment bills where diagnostic or procedure coding
was in error. Adjustments reported by the QIO have no corresponding time limit and are
adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an
adjustment bill. However, if diagnostic and procedure coding errors have no effect on the
DRG, adjustment bills are not required.
Under PPS, for long-stay cases, hospitals may bill 60 days after an admission and every 60
days thereafter if they choose. The A/B MAC (A) processes the initial bill through
Grouper and Pricer. The provider must submit an adjustment to cancel the original
interim bill(s) and rebill the stay from the admission date through the discharge date.
When the adjustment bill is received, it processes it as an adjustment. In this case, the 60-
day requirement for correction does not apply.
Where payment is handled through cost reporting and settlement processes, the provider
accumulates a log for those items not requiring an adjustment bill. Maryland inpatient
hospital providers also keep a log of late charges when the amount is under $500. They
submit the log with their cost reports. After cost reports are filed, the A/B MAC (A)
makes a lump sum payment to cover these charges as shown on the summary log. The
provider uses the summary log for late charges only under cost settlement (outpatient
hospital), except in Maryland.
