Box - 22 - Medicaid resubmission status - how to use

Billing instruction for Ambulance Billing - Box 20 to 23

BlockNo.	Block Name	Block Code	Notes
20	Outside Lab?	LB	Do not complete this block.
21	Diagnosis or Nature of Illness or Injury	M/A	Enter the most specific three-, four-, or five-digit ICD-9-CM code that describes the diagnosis. The primary ICD-9-CM code block (21.1) must be completed. The second, third, and fourth diagnosis codes must be completed if applicable.
22	Medicaid Resubmission	A/A	This block has two uses: 1)  When resubmitting a rejected claim. If resubmitting a rejected claim, enter the 13- digit internal control number (ICN) of the ORIGINAL rejected claim in the right portion of this block (e.g., | 1103123523123). 2)  When submitting a claim adjustment for a previously approved claim. If submitting a claim adjustment, enter ADJ in the left portion of the block and the LAST APPROVED 13-digit ICN, a space and the two-digit line number from the RA Statement in the right portion of the block (e.g., ADJ | 1103123523123 01). Note: If your claim was submitted prior to the implementation of PROMISe™, enter the 10-digit claim reference number (CRN) in place of the ICN.
23	Prior Authorization Number	LB	Do not complete this block.

Medicaid Resubmission Code and Original Reference Number: Complete only if replacing or voiding/canceling a previously paid claim. If submitting a replacement claim, enter resubmission code 7 in the left side of item 22 and enter the 10- digit CRN of the paid claim you are replacing in the right side of item 22. If submitting a void/cancel claim, enter resubmission code 8 in the left side of item 22 and enter the 10- digit CRN of the paid claim you are voiding/canceling in the right side of item 22.


Instructions: When resubmitting a claim, enter the appropriate claim frequency code left justified in the left-hand side of the field.

7 – Replacement of prior claim
8 – Void/cancel of prior claim