Fee Schedule and Patient Credit File Updates

Date: 12/17/24

Providers, please review Meridian’s process to adjust claims when retro rates and patient liability information is received from HFS.

When Meridian receives an updated fee schedule from the Department of Healthcare and Family Services (HFS), action will be taken to adjust claims to reflect the new fee if the updates are not loaded before an effective date. This includes an additional payment when the fee increases or recoupment of overpayment if the fee decreases.

Adjustment should occur within 45 days of the receipt of updated HFS information. Adjusted claims will appear on the 835 file or an Explanation of Payment. A list of fee schedule changes and status of claims reprocessing are located at Fee Schedule and Program Changes.

Claim adjustments also apply to changes in patient liability reported in the Patient Credit File (PCF). The PCF is received weekly and incorporates data about eligible services, including patient cost share amounts for members residing in nursing facilities, SMRHF, SLP, and receiving hospice services. The PCF reports member cost share for a rolling 36-month period.

Meridian reviews facility and hospice claims weekly based on changes to the patient’s income received in the file from HFS. As a reminder, claims impacted will be adjusted weekly to reflect the updated patient income amount noted in the file. The reprocessing of these claims includes additional payment and reversal of payment-based PCF updates.

Providers will be informed that a claim has been reprocessed based on updates to patient income on the 835 file or EOP with the explanation code, Pf: “Claim adjusted due to income change on PCF file.”

If you have questions, please contact Provider Services at 866-606-3700 or reach out to your Provider Relations contact. The preferred and quickest way to access current claim statuses is via the Meridian Secure Provider Portal.