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Ohio Laws and Rules
With the exception of medicare crossover payments, pharmacy claims are to be adjusted through the Ohio department of job and family services (ODJFS) point-of-sale pharmacy provider.
Adjustments to nursing facility room and board payments must be in accordance with rule 5101:3-3-39.1 of the Administrative Code.
(A) Errors in payment may be corrected electronically or by completing the appropriate paper adjustment request form.
(B) A claim adjustment for services rendered that require attachments for processing must be submitted on the appropriate paper adjustment form. If documentation or attachments are not required, the adjustment request may be submitted electronically.
(C) Errors in payment may be voided, or voided and replaced, by the electronic data interchange (EDI) 837 adjustment transaction, even if the original claim was submitted on a paper claim form. Providers that submit EDI 837 health care claim transactions either as a trading partner or through a trading partner, and choose to submit electronic adjustments, must submit electronic adjustments as an authorized trading partner or through an authorized ODJFS trading partner. All EDI adjustments are credited against future payments.
(D) Errors in payment may be corrected by completing the appropriate paper adjustment request form. The proper usage for each form is as follows:
(1) The JFS 06766 “Adjustment Request Form-Hospital Only” (rev. 11/2005):
(a) To be used by hospitals only.
(b) To adjust a portion of the medicaid claim payment against future payments.
(c) To credit entire amount of medicaid claim payment against future payments when the claim paid date is three hundred or more days old.
(d) To adjust a gross adjustment claim.
(e) Include a copy of the paid remittance advice.
(2) The JFS 06767 “Adjustment Request Form” (rev. 11/2005):
(a) To be used by all providers other than hospitals, nursing facilities, intermediate care facilities for the mentally retarded, and pharmacies.
(b) To adjust a portion of the medicaid claim payment against future payments.
(c) To credit an entire amount of medicaid claim payment against future payments when the claim paid date is three hundred or more days old.
(d) To adjust a gross adjustment claim.
(e) Include a copy of the paid remittance advice.
(3) The JFS 06768 “Claim Credit Reversal Form” (rev. 02/2001):
(a) To be used by all providers except nursing facilities, intermediate care facilities for the mentally retarded, and pharmacies.
(b) To credit the entire amount of the medicaid claim payment against future payments when the claim paid date is less than three hundred days old.
(c) To adjust a claim with a paid status of zero payment when the claim paid date is less than three hundred days old.
(d) This form cannot be used to adjust a gross adjustment claim.
(e) This form cannot be used when reimbursing ODJFS with a check.
(E) Providers submitting an adjustment for a claim that has been underpaid (i.e., line items or entire claims having an erroneous payment or are in a paid status with a zero payment) must submit the request within one hundred eighty days from the date the claim was paid.
If a third party payer adjusts or recoups payment for a claim, and the provider has previously submitted to ODJFS a claim for cost sharing beyond third party payment, the provider must ascertain any payments owed to, or owed by, ODJFS and abide by all third party liability regulations in accordance with rule 5101:3-1-08 of the Administrative Code and the timely filing limitations in accordance with rule 5101:3-1-19 of the Administrative Code.
(F) All overpayments must be refunded to ODJFS with no exceptions. The provider is responsible for program compliance as specified in division 5101:3 of the Administrative Code.
(G) There are two ways monies can be refunded to ODJFS.
(1) ODJFS may debit the provider against future payments. If the debit against future payments is initiated by the provider, the provider must do one of the following:
(a) Submit a completed JFS 06766 or JFS 06767 in accordance with paragraph (D)(1) or (D)(2) of this rule. A separate line on the form must be completed for each claim for which a refund is being made.
(b) Submit a completed JFS 06768 in accordance with paragraph (D)(3) of this rule.
(c) Submit an EDI 837 adjustment transaction.
(2) The provider may remit a check to the ODJFS. If the provider chooses to send a check the check must be accompanied by a completed JFS 06766 or JFS 06767 as appropriate. A separate line on the form must be completed for each claim for which a refund is being made. The check must be made payable to treasurer of state, state of Ohio.
(H) If all claim payments on the medicaid warrant are either incorrect or are for consumers for which no services had been rendered by the provider that received payment, the provider shall not deposit the warrant. The provider must return the warrant along with the corresponding medicaid remittance advice and a letter explaining the discrepancy. ODJFS will cancel or void the warrant and will credit or debit all claims on the warrant against future payments. The credit or debit will be reflected on a new warrant and future remittance advice. After the credit or debit appears on the new remittance advice, the provider may submit corrected claim billings for payment.
(I) Overpayments are recoverable by ODJFS at the time of discovery. Appeal rights under Chapter 119. of the Administrative Code may be exercised to the extent provided in accordance with rule 5101:3-1-57 of the Administrative Code. All recoverable amounts are subject to the application of interest in accordance with rule 5101:3-1-25 of the Administrative Code.
Effective: 05/23/2007
R.C. 119.032 review dates: 03/06/2007 and 05/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 6/3/83, 2/1/84, 10/1/84, 7/11/85 (Emer), 9/30/85, 10/1/87, 7/1/90, 7/1/02, 10/16/03 (Emer), 1/1/04, 4/1/05, 7/1/05