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

When you receive a rejection, or you have a claim or billing problem, how do you correct the encounter information and then resubmit the corrected claim?

Check out the procedures below to learn how to update and resubmit a claim. This article starts with a “quickstart” simplified guide and then goes into more detail. You can read how to manage charge corrections, payments already received, payer requirements, and the more advanced needs of corrected claims.

Make Changes, Add Reference/Resubmission Numbers, and Then Resubmit: To resolve a claim problem, typically you will edit the charges or the patient record, add the payer claim control number, and then resubmit or “rebatch” the claim. Make sure you always perform that final step–otherwise the changes you made to the charges won’t make a difference.

Quickstart: How to Resubmit a Single Claim

Read the procedure below to learn the basics of how to resubmit a single 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 CPT code, or similar.

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 F4Insurance Status or F5Visit 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 Claim Delay Reason and/or Payer Claim Control Number

For most resubmission reasons, you need to find and enter a Claim Delay Reason and a claim Reference Number from the payer (the Payer Claim Control Number). For more information, read the procedures and sections below.

Press F5Visit Status and enter the numbers of all charges in the visit. 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.

Press [F3 — Batch Claim]

Press F3Batch 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.

Confirm Your Selection

Review the charge items you have selected and press Y to confirm.

Run Claims

The next time you run your claims, the newly batched visit will be resubmitted.

Find the Payer Claim Control Number

The first step for any claim correction job is to find out if a claim went out already. If it did, you’ll need to find out the Payer Claim Control Number in order to resubmit the claim.

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 F3See 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.

Payments Already Posted? Unlink and Adjust Them Off

If payments and/or adjustments have already been posted against the charges, you may need to unlink the payments and post an accounting adjustment. The insurance payer will likely ask for the money refunded back as a “take back” on future ERAs. That means that a future check, for an unrelated encounter, may be reduced for the amount of a payment sent to you in error.

Follow the procedure below to post a temporary refund to hold the payments or adjustments for a claim you need to 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 F6Unlink & 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.

What About Adjustments From the Insurance Company?: If you are correcting a claim and there are already adjustments linked to charges you need to delete, you can safely delete them. Payments need to be accounted for later in your balance and reports, but adjustments do not.

Make Account and Charge Corrections For the Claim

After the above considerations, you are ready to update actual information that appears on a claim. Read the sections below for some examples.

Fix Incorrect Demographic and Insurance Information

Many common claim errors are due to incorrect demographic or insurance information.

You can fix patient birth date and other demographic information in PCC EHR or in the Patient Editor (otjane).

You can fix policy information in the Policies component in PCC EHR or the Insurance Policies program (policy).

Relationship to Insured: One common mistake that leads to claim rejections is an incorrect “Relationship to Insured”. For any medicaid-type plan, the relationship should be “Self”. Otherwise, in a pediatric environment PCC recommends you use the “Child” relationship.

Change the Responsible Party or Copay Amount for a Claim’s Charges

You may need to change the responsible party (an insurance policy, Medicaid, or personal) for some or all of the charges on a claim. You may also need to change the copay amount connected with the office visit charge.

You can make these changes in Correct Mistakes (oops), using F4Insurance Status.

Read the Change the Responsible Party for Charges reference article to learn more.

Change or Add a Diagnoses Code, Claim Reference Numbers, or Attachments

You may need to edit the ICD-10, claim reference numbers, or add attachments to a claim and then resubmit it.

You can make these changes in Correct Mistakes (oops), using F3Visit Status.

Read the Visit Status Screen: Edit Diagnoses, Billing Provider, and Other Visit and Claim Information reference article to learn how to change diagnoses and claim information for charges.

Read Send Attachment Codes on PCC Claims to learn how to create and add attachment codes to a claim.

Add a Procedure Modifier to a Code (-25, etc.)

Sometimes you may need to add a modifier, such as -25, to a charge. You can do that in Correct Mistakes (oops) using F5Visit Status.

Read the Change Procedure Code Modifiers After Posting Charges article section to learn how.

Code Missing?: If you can’t find the modified code that you need, then your practice has not set up that procedure for billing in your Procedures table. Ask your practice’s billing administrator to add the modified code as a procedure in the Table Editor (ted), with appropriate code and price.

Remove an Incorrect CPT Code From a Visit

If a visit has the wrong charge on it, you must delete the incorrect CPT in oops. You may need to first handle any payments or adjustments attached to the charge as described above. Then you can delete the incorrect charges and post the correct charges. (As noted above, if the claim has already been sent, you’ll need to include the Payer Claim Control Number for resubmission.)

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 F5Visit 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 CPTs

Next, use F8Delete Items to delete the incorrect charges.

Post the Correct CPTs in Checkout

See the procedure below.

Add a New (or Corrected) CPT Code to a Visit

If you need to add a new CPT code to a claim, perhaps after you delete the incorrect one, follow this procedure.

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, diagnoses, provider, and location. You can press F5Visit 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.

Post New Charges for the Visit

Run the Post Charges (checkout) program. Press F12 to skip the visit selection process and search for the patient. Post all visit information. Be sure to include the exact charge date, provider, location and diagnoses and procedures. Use diagnosis letters to link diagnoses to procedures.

Before you save your charges, press F5Claim Info and enter the Payer Claim Control Number in the Reference field, and optionally enter a Claim Delay Reason.

Press F1 to save the charges, F1 again to continue to the payment screen, and F1 to post the new charge(s).

Rebatch and Resubmit the Claim

After you make changes to a visit’s charges, such as adding a missing diagnosis code, deleting an incorrect CPT, or changing the responsible party, you must re-batch the claim so it can be submitted. You should also record what happened in the account record.

If the Claim Was Already Sent, Add Payer Claim Control Number to All Charges

As noted above, if the claim was already sent, you must add the Payer Claim Control Number to all charges on the claim.

Open the Correct Mistakes oops program for the patient or insured family member. Press F5Visit Status and select all charges for the visit. Page down to the Claim Information screen and enter the Payer Claim Control Number in the Reference Number field. If appropriate, enter a Claim Delay Reason.

Re-batch the Claim

Use F2Generate Claim to re-batch a claim. You can read Resubmit a Claim for more details.

  • Last modified: April 27, 2020