Provided on this page are general reminders and specific billing instructions for adjusting or voiding a HCFA-1500 claim form.
To adjust or void a CMS-1500 claim form, the provider must use a 213 Adjustment/Void Form.
Only a paid claim can be adjusted or voided. If a paid claim is being adjusted, the Provider Identification Number and the Recipient/Patient Identification Number cannot be changed.
For those claims where multiple services are billed, the Adjustment/Void Form allows the adjustment or voiding of only one line. A separate Adjustment/Void Form is required for each claim line if more than one claim line on a multiple line claim form needs to be adjusted or voided.
The provider should complete the information on the adjustment form exactly as it appeared on the original claim, changing only the item that was in error and noting the reason for the change in the space provided on the claim.
If a paid claim is being voided, the provider must enter all the information from the original claim exactly as it appeared on the original claim. After a voided claim has appeared on the Remittance Advice, a corrected claim may be resubmitted (if applicable).
When an Adjustment/Void Form has been processed, it will appear on the Remittance Advice under Adjustment or Voided Claim. The adjustment or void will appear first. The original claim line will appear in the section directly beneath the adjustment/void section.
An Adjustment/Void will generate Credit and Debit Adjustments which will appear in the Remittance Summary on the last page of the Remittance Advice.
Click here for a downloadable copy of the 213 Adjustment/Void Form and instructions.