Correct a Claim: How to Fix and Resubmit an Insurance Claim

Update and Fix Charge, Encounter, Patient and Account Information

Confirm that patient and account information is correct and that the charges are now pending the correct insurance plan. Correct whatever errors lead to either a claim rejection, or that relate to why you need to resubmit the claim. For example, you may have needed to add an attachment, fix a procedure code, or similar.

To learn more, check out:

• Edit Encounter Charge Information and Generate a New Claim (15 minutes • 2008)
• Adjust Charge Details and Claim History (Correct Mistakes)
• Change the Responsible Party and Copay for Charges
• Edit an Encounter’s Diagnoses, Billing Provider, and Other Claim Information

Run oops For the Account

You can find the oops program in the Daily Operations window or reach it by pressing the Correct Mistakes function key in many Partner programs, such as Checkout or Interactive Inscoar.

Identify Charges You Wish to Resubmit

Page down and find the charges that need to be resubmitted. You can use the F4 – Insurance Status or F5 – Visit Status function keys to review or change details about the charges. In most cases, you should identify all the charges from a visit date.

Usually: Enter a Claim Delay Reason and Payer Claim Control Number

For most resubmissions, you need to enter a Claim Delay Reason and a claim Reference Number from the payer (the Payer Claim Control Number).

Press F5 – Visit Status and select all charges in the visit, or enter the claim ID. Then press Page Down to visit the Changing Visit Information screen and enter a Claim Delay Reason and Reference Number.

In most situations, the Claim Delay Reason will be “09 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules”. The correct claim Reference Number must be supplied by the payer–you can find it on an EOB or on an acknowledgement from the payer.

To learn how to find the claim Reference number, read the sections below. To learn more about Claim Delay Reason, Reference Number, and other claim information attached to charges, see Edit Accident Information Authorization Numbers and Other Visit Status Information for the Claim.

Press [F2 — Generate Claim]

Press F2 – Generate Claim. Do this for either a paper or electronic claim, as F3 prepares a claim for either HCFA printing or electronic submission.

Select Charges to Rebatch

Enter the item numbers of the charges that need to be resubmitted and press Enter. Alternatively, press F3 – Enter Claim ID or F4 – Enter Date to quickly select all charges for a given encounter.

Print a HCFA or Batch an Electronic Claim

Review the charges and press F3 – Print Claim or F4 – Batch Claim.

If More Than One Policy is Available, Select an Insurance Batch

If multiple insurance policies are available for the charges, PCC will ask you which one to use for the claim. Claim batches are used for claim configuration. Select an option and press Enter.

Review the Billing Message in the History

Whenever you generate a claim, PCC records how and when it was done in the account’s billing history.

Optionally, Enter an Account Note

If you’ve made changes to charges, payments, or the patient or family record, you may want to record your action so you can understand it later when you review billing history.

You can create a note in oops, or in PCC EHR.

Submit Claims

The next time you process claims, any newly batched electronic claims will be reprocessed and submitted.

Open Correct Mistakes (oops) For Account

First, run the oops program for the patient or insurance subscriber.

Find Out if a Claim Went Out

Page down until you find the charges for the date of service. You can see all billing and claim history on the main charge history screen.

If a claim has been submitted, you will see “Aetna HCFA CLAIM ID” or “Aetna ECS CLAIM ID” or similar. After the CLAIM billing message, you will see one or more clearinghouse or payer response reports.

If a Claim Went Out, Look Up the Payer Claim Control Number

You will need the Payer Claim Control Number in order to submit a corrected claim. Press F3 – See Claim Report or Bill and enter the number next to the payer response report.

Payer response reports look different depending on the payer, but with practice you can learn to quickly identify the Payer Claim Control Number. (It may also be called the “Payer Trace Number”).

Write down the Payer Claim Control Number. You’ll need it when you resubmit.

Open the refund Program

Run the Post Accounting Adjustments By Patient (refund) program and find the appropriate account.

Post a “Ins May Request Refund” Adjustment

Post an accounting adjustment equal to the dollar amount that is currently linked to the claim’s charges.

Can't Find the Procedure?: Your practice can have its own custom set of accounting adjustments, with names that match your usual workflow. Contact PCC Support if you need help creating new adjustment types.

Link the Payment to Your Adjustment

Open Correct Mistakes (oops) for the account and press F6 – Unlink & Relink to relink the payment to your new adjustment. To see an example, read Relink a Payment.

Record Your Actions

After you make these changes, you should record what you did on the account. You can add a visit-level note from the Insurance Status or Visit Status screens, or use the Family Editor (fame).

Later, Change to a Take-Back or Other Account Adjustment

If the insurance company requests a refund because of the claim correction, you can post a different accounting adjustment, such as “Insurance Take-Back” and relink the payment to that adjustment.

Find the Charges and Note Important Claim Information

First, open the oops program for the patient or insured family member. Page down to review the charge history. Make note of the charge date, diagnoses, provider, and location. You can press F5 – Visit Status to review more detailed information about any charge. You can also use the Account History report (tater).

Claim Already Received By Payer?: As discussed in the procedures above, if the claim has already been received by the payer, you’ll need to look up the Payer Claim Control Number before proceeding. If payments and adjustments were posted, you’ll need to unlink them from the invalid charge as well. See the procedures above to learn how.

Delete the Incorrect Charges

Next, use F8 – Delete Items to delete the incorrect charges.

Post the Correct Charges in Checkout

See the procedure below.

Find the Visit and Note Important Claim Information

First, open the oops program for the patient or insured family member. Page down to review the charge history. Make note of the charge date. You can press F5 – Visit Status to review more detailed information about any charge. You can also use the Account History report (tater).

Claim Already Received By Payer?: As discussed in the procedures above, if the claim has already been received by the payer, you’ll also need to identify the Payer Claim Control Number before proceeding, in order to file a corrected claim. If any payments and adjustments are already posted against the charges, you’ll need to unlink them from the invalid charge as well. See the procedures above to learn how.

Post New Charges for the Visit

In the Billing History section of the patient’s chart, double-click on the encounter to edit it. Verify that you are working with the correct encounter using the information you noted above. Enter the new charges. Be sure and link procedures to the appropriate diagnoses.

Alternatively, you can post new charges in the Post Charges (chuck) program, but you will need to manually enter the encounter date, diagnoses, provider, and location.

If Already Submitted and Acknowledged By the Payer, Enter the Payer Claim Control Number

If the claim has already been acknowledged by the payer, you must add a Claim Delay Reason and the Payer Claim Control Number to all charges for the encounter. In oops, press F5 – Visit Status, select all charges, and page down to adjust the Reference Number and Claim Delay Reason fields.

See the procedure above to learn more.