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RTD Form Completion for ICD Indicator Errors

January 5, 2015

The Resubmission Turnaround Document (RTD) (Form 65-1) completion instructions are updated to illustrate how RTDs are completed for Payment Request for Long Term Care (25-1) claims that were submitted with incorrect or missing ICD indicators.

In the Correct Information field of the RTD form, providers submit the correct ICD indicator and diagnosis code information on separate lines, as follows:

RTD Form Completion for ICD Indicator Errors

F.I. Use Only Field
The Field box identifies a claim field.

  • Field 362 identifies the ICD indicator on the 25-1 claim.
  • Field 363 identifies the Primary Diagnosis Code on the 25-1 claim.

Correct Information Field

  • In section B of the RTD form, enter correct information in the numbered box that corresponds with the error line in the Information Block field of section A. If the information in section A is correct, leave the corresponding line blank.
  • If the F.I. Use Only section lists field 362 as requiring correction, enter ICD indicator “9” on the corresponding line in the Correct Information area. Do not add the diagnosis code on the same line.
  • If the F.I. Use Only section lists field 363 as requiring correction, enter the appropriate diagnosis code on the corresponding line in the Correct Information area. Do not add the ICD indicator “9” in front of the diagnosis code.