Thursday, May 5, 2011

corrected claim - replacement of prior claim - UB 04

Corrected Claims

A corrected claim is a claim that has already been processed, whether paid or denied, and is  resubmitted with additional charges, different procedure or diagnosis codes or any information that would change the way the claim originally processed.

Claims returned requesting additional information or documentation should not be submitted as corrected claims. While these claims have been processed, additional information is needed to finalize payment.

Note: BCBSF does not consider a corrected claim to be an appeal. When submitting a paper corrected claim, follow these steps:

• Submit a copy of the remittance advice with the correction clearly noted.

• If necessary, attach requested documentation (e.g., nurses notes, pathology report), along with the
copy of the remittance advice. To ensure documents are readable, do not send colored paper or
double-sided copies.

• Boldly and clearly mark the claim as “Corrected Claim” and attach the completed Provider Claim
Inquiry Form (available at www.bcbsfl.com). Failure to mark your claim appropriately may result in
rejection as a duplicate.

• If a modifier 25 or 59 is being appended to a CPT code that was on the original claim, do not submit
as a “Corrected Claim” instead, submit as a coding and payment rule appeal with the completed
Provider Appeal Form (available at www.bcbsfl.com) and supporting medical documentation (e.g.,
operative report, physician orders, history and physical)

When submitting an electronic corrected claim through the Availity Health Information Network, use the Bill and Frequency Type codes listed below.

• 7 – Replacement of Prior Claim

If you have omitted charges or changed claim information (diagnosis codes, dates of service, member
information, etc.), resubmit the entire claim, including all previous information and any corrected or
additional information. Hospitals and facilities should include the seven in the third digit of the Bill
Type. Physicians should submit with a Frequency Type code of seven.

• 8 – Void/Cancel of Prior Claim

If you have submitted a claim to BCBSF in error, resubmit the entire claim. Hospitals and facilities
should include the eight in the third digit of the Bill Type. Providers should submit with a Frequency
Type code of eight. If the claim was paid, resubmit the claim to BCBSF via paper and attach a check
for the amount that was paid in error.


Resubmission of a corrected claim 

Consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements, submit corrected claims in their entirety.

If a claim needs correction, please follow these guidelines:

** Make the necessary changes in your practice management system, so the corrections print on the amended claim.

** Attach the corrected claim (even line items that were previously paid correctly). Any partiallycorrected request will be denied. Enter the words, “Corrected Claim” in the comments field on the claim form. Your practice management system help desk or your software vendor can provide specific instructions on where to enter this information in your system. If you do not have this feature, stamp or write “Corrected Claim” on the CMS 1500 form. Changes must be made in your practice management system and then printed on the claim form. You may not write on the claim itself.

** The resubmitted claim is compared to the original claim and all charges for that date of service. The provider and patient must be present on the claim, or we will send a letter advising that all charges for that day are required for reconsideration.

** Complete the Claim Reconsideration Request form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

UB04: UB Type of Bill should be used to identify the type of bill1 submitted as follows:

** XX5 Late Charges
** XX7 Corrected Claim
** XX8 Void/Cancel previous claim

Resubmission of Prior Notification/Prior Authorization Information Submit a prior authorization number and other documents that support your request. If you spoke to a customer service representative and were told that notification was not required, please submit the date, time and reference number of that call and the name of the representative handling the call. Please also advise if the service was performed on an emergency basis and therefore notification was not possible.

Resubmission of a claim with bundled services Review your claim for appropriate code billing, including modifiers. If the claim needs to be corrected, please submit a corrected claim. If a bundled claim is not paid correctly, submit a detailed explanation including any pertinent information on why the bundling is incorrect.


REPLACEMENT CLAIMS (ADJUSTMENTS)

Replacement claims are submitted when all or a portion of the claim was paid incorrectly or a third-party payment was received after MDHHS made payment. When replacement claims are received, MDHHS deletes the original claim and replaces it with the information from the replacement claim. It is very important to include all service lines on the replacement claim, whether they were paid incorrectly or not.

All money paid on the first claim will be recouped and payment will be based on information reported on the replacement claim only. Examples of when a claim may need to be replaced:


** To return an overpayment (report "returning money" in Remarks section);

** To correct information submitted on the original claim (other than to correct the provider NPI number and/or the beneficiary ID number). Refer to the Void/Cancel subsection below;

** To report payment from another source after MDHHS paid the claim (report "returning money" in Remarks section); and/or

** To correct information that the scanner may have misread (state reason in Remarks section).

To replace a previously paid claim, indicate 7 (xx7) as the third digit in the Type of Bill Form locator frequency. Providers must enter the 18-digit Transaction Control Number (TCN) of the last approved claim being replaced and the reason for the replacement in Remarks. The provider NPI number and beneficiary ID number on the replacement claim must be the same as on the original claim. Providers must enter in Remarks the reason for the replacement. Refer to the Void/Cancel subsection below for
additional information. To replace a previously paid claim adjudicated with a Claim Reference Number (CRN) prior to October
1, 2007, both the Medicaid legacy provider ID number and the NPI must be reported on the replacement claim for successful adjudication.


VOID/CANCEL A PRIOR CLAIM

If a claim was paid under the wrong provider NPI or beneficiary ID Number, providers must void/cancel the claim. To void/cancel the claim, indicate an 8 in the Type of Bill (xx8) as the third digit frequency.

The 8 indicates that the bill is an exact duplicate of a previously paid claim, and the provider wants to void/cancel that claim. The provider must enter the 18-digit TCN of the last approved claim or adjustment being cancelled and enter in the Remarks section the reason for the void/cancel. A new claim may be submitted immediately using the correct provider NPI or beneficiary ID number.

A void/cancel claim must be completed exactly as the original claim. To void/cancel an original claim adjudicated with a Claim Reference Number (CRN) prior to October 1, 2007, both the correct Medicaid legacy provider ID number and NPI must be reported along with the correct beneficiary ID number.

No comments:

Post a Comment

Popular Posts