​Claim investigation and corrected claim submission procedures

November 4, 2020

To help expedite your claim review requests submitted through the Claim Investigation transaction on the NaviNet® web portal (NaviNet Open), we would like to remind providers that claim edits and claim corrections are not permitted through the Claim Investigation transaction.

If you need to edit any data field on a claim, a corrected claim must be submitted with the new information, and you need to note the original claim number on the corrected claim. You must submit a new claim through one of the following methods:

  • Electronic claim
  • 1500 Claim Submission transaction on NaviNet Open
  • Paper claim

Proper submission instructions for each method are detailed below.

Corrected claims

The term “corrected claim” is meant for corrections to claims that were processed and finalized in the adjudication system and for which a claim number was assigned. By submitting a corrected claim, the provider wishes to have the following performed on the original claim:

  • replacement of prior claim (correction of the charges/services/diagnosis/modifier originally submitted by the provider);
  • void/cancellation of prior claim (reflecting the elimination of a previous claim in its entirety);
  • addition of late charges to an institutional claim after the original claim was processed.

The corrected claim must be submitted under the same National Provider Identifier (NPI) or member ID as the original claim. If a claim was originally submitted under the wrong NPI or member ID, you must submit a void request for the original claim number. Once the claim has been voided, you can then submit a new claim under the correct NPI or member ID.

Providers must follow the instructions detailed in the following sections to ensure their corrected claims are accurately processed in a timely manner. A common billing error is to resubmit an original claim type versus following the corrected claim submission instructions below. If more than one original claim type is received for the same encounter, it may be denied as a duplicate with reference to rebill as a corrected versus original claim submission.

Electronic claims

As a reminder, there are specific guidelines in the AmeriHealth versions of the HIPAA Transaction Standard Companion Guide that providers must follow when resubmitting a claim for an adjustment. In order for the adjustment to occur, the following Loop ID/Reference segments must be populated accordingly:

  • Loop ID: 2300, Reference: CLM05-3 (Claim Frequency Type Code);
  • If CLM05-3 contains 5 (Late Charge(s) – institutional only), 7, or 8, prior claim information is required. The following segments are required in Loop 2300:
    • REF – Payer Claim Control Number (REF01 = F8 and AmeriHealth Claim Number in REF02)
    • NTE – Billing Note (NTE01 = ADD and detailed description regarding the adjustment in NTE02)

Claim resubmission

Claim Frequency Type Codes that tie to a "prior claim" or "finalized claim" refer to a previous claim that has completed processing in the payer's system and has produced a final paper/electronic Provider Explanation of Benefits (professional) or Provider Remittance (facility).

Please note the following:

  • Previous claims that are pending due to a request from the payer for additional information are not considered a "prior claim" or "finalized claim.”
  • An 837 professional claim transaction is not an appropriate response to a payer's request for additional information. Rather, providers must follow the instructions within the request for returning the additional information. Currently, there is no EDI transaction available to return the requested information.
  • Previous claims that were rejected for “front-end” edits via the 277CA (electronic) or rejection letter (paper) are not considered candidates for “corrected claim” submission. These previous claims did not have claim numbers assigned nor was a final Provider Explanation of Benefits (professional) or Provider Remittance (facility) produced. Net new claims will need to be submitted with the updated data resolving the reason for rejection.
  • When submitting “corrected claims,” please be sure to include:
    1. all services originally billed and not just the service that needs correction;
    2. the original claim number.

For more information about electronic claim submission guidelines, refer to the appropriate HIPAA Transaction Standard Companion Guide for AmeriHealth New Jersey or AmeriHealth Pennsylvania, available on the Trading Partner Business Center.

NaviNet Open transaction: 1500 Claim Submission

Providers may submit certain corrected claims through the 1500 Claim Submission transaction. This transaction can be used to expedite local professional corrected claims with a frequency code: 7 = Replacement of prior claim or a frequency code: 8 = Void/cancellation of prior claim.

When using Claim Frequency Type Code 7 (Replacement of prior claim) or 8 (Void/cancellation of prior claim), the provider must complete the Original Claim Number field.

A notes field is available in the Remarks section of the 1500 Claim Submission – Header to provide a detailed description.

For further instructions on how to use the 1500 Claim Submission transaction, please read the Claim Submission Guide, which can be found under User guides and webinars in the NaviNet Open section.

Paper claims

CMS-1500 claim form

Box 22 – Resubmission and/or Original Reference Number Follow the instructions from the National Uniform Coding Committee (NUCC) billing requirements:

  • List the original reference number for resubmitted claims.
  • When submitting a claim, enter the appropriate resubmission code in the left-hand side of the field.
    • 7 = Replacement of prior claim
    • 8 = Void/cancellation of prior claim

Example:

 

For more information, please refer to the 1500 Claim Form Reference Instruction Manual, which is available by selecting 1500 Instructions from the 1500 Claim Form tab on the NUCC website.

UB-04 claim form

Field location 4 – Type of Bill – Frequency Code

When submitting a claim, enter the appropriate Frequency Code in the fourth position of the Type of Bill:

  • 5 = Late Charge(s) only
  • 7 = Replacement of prior claim
  • 8 = Void/cancellation of prior claim

Field location 64 – Document Control Number

This field is used to capture the original reference/claim number, which is required for corrected claims.

 

Learn more

If you have additional questions, please contact our Provider eBusiness team through our online Provider eBusiness Inquiry form for AmeriHealth New Jersey and AmeriHealth Pennsylvania.

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