QUEST Integration – Resubmissions and Corrections to Previously Processed Claims

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Corrections may be needed for claims that have already been processed. The instructions below apply to paper claim submissions. Please follow the instructions below to ensure that HMSA QUEST Integration can identify the original claim, understand the correction that is required, and ensure that the resubmitted claim is not denied as a duplicate. Instructions for submitting electronic submissions are outlined in your Trading Partner Manual.

Corrected claims must be submitted no later than 365 days from the earliest date of service on the claim.

1. CMS 1500 Claims – Original claim was denied or partially denied

   1. Denial due to request for attachments (e.g., operative notes, primary carrier EOB, etc.)

      Claim must be submitted on paper. Complete a duplicate of the previously processed claim and add the information below. Claims that are submitted without the information below will be returned or denied as duplicates. Do not file another claim with attachments if the claim had originally been filed with attachments and had already been reviewed by a Medical Director or Medical staff. In order to dispute the outcome of a claim reviewed by Medical Staff, please submit a provider correspondence inquiry, fee inquiry, or a claim reconsideration request.

      Requirement	Paper CMS 1500
      Indication of replacement claim	Block 22 – Medicaid Resubmission Code: Code = 7 (Replacement)
      Original HMSA QUEST Integration claim ID	Block 22 – Medicaid Resubmission Code: Original Ref No. must contain Original QUEST Integration claim ID
      Reason for correction	Block 19 – Reserved For Local Use: Include text explaining reason for attachments

   2. Denial requiring corrected claim information (e.g., incorrect diagnosis codes, add a modifier, etc.)

      Electronic resubmission is preferred to paper claim. Submit a claim with the corrected claim information and all the correct services originally billed. Corrected claims that are submitted without the information below will be returned or denied as a duplicate. If the amount paid or reason for denial of services as billed on the original claim is being disputed submit a provider correspondence inquiry, fee inquiry or a claim reconsideration request rather than resubmit the claim. Note: Outpatient lab claims correcting previously billed diagnosis codes must include documentation of the corrected diagnosis codes from the physician that ordered the lab test(s). Attach the Additional Dx Form signed by the ordering physician to the corrected paper claim.

      Requirements	Electronic 837P Version 5010	Paper CMS 1500
      Indication of replacement claim	Loop 2300 CLM05-3 (Claim Frequency Code) = “7” (Replacement)	Block 22 – Medicaid Resubmission Code Code = “7” (Replacement)
      Original HMSA Claim ID	Loop 2300 REF – Payer Claim Control Number REF01 = “F8” (Original Reference Number) REF02 = Original HMSA Claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID
      Reason for correction	Loop 2300 NTE – Claim Note Segment NTE01 = “ADD” NTE02 = text explaining reason for correction Optional – NTE segment at Loop 2400 line level if more space is needed.	Block 19 – Reserved For Local Use Include text explaining reason for correction

2. Original claim was paid by HMSA QUEST Integration or is in process

   A claim that is paid or in process may be voided and an entirely new claim submitted, or if the claim was paid you may submit corrections to a paid claim.

   1. Void/cancel a paid claim or claim in process

      Electronic resubmission is preferred to paper claim. Claims that were filed in error or filed under the wrong patient may be cancelled by submitting a void claim as soon as you discover the error rather than wait for the claim to be fully processed. The void claim must contain the exact claim data as submitted on the original claim. Void claims that are submitted without the information below will be returned or denied as duplicates. A new claim can be submitted when the void claim is processed. The new claim will not be considered a duplicate to the original and can be filed as if no previous claim was ever submitted.

      Requirement	Electronic 837P Version 5010	Paper CMS-1500
      Indication of void claim	Loop 2300 CLM05-3 (Claim Frequency Code) = “8” (Void)	Block 22 – Medicaid Resubmission Code Code = “8” (Void)
      Original HMSA Claim ID	Loop 2300 REF – Payer Claim Control Number REF01 = “F8” (Original Reference Number) REF02 = Original HMSA Claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID

   2. Submit corrections to a paid claim

      Electronic resubmission is preferred to paper claims. Submit a claim with the corrected claim information and the correct services originally billed. Corrected claims must also have the following information or they may be returned or denied as duplicates. Do not file another claim if the amount of payment or reason for denial is being disputed. Submit a provider correspondence inquiry, fee inquiry, or a claim reconsideration request.

      Requirement	Electronic 837P Version 5010	Paper CMS-1500
      Indication of the replacement claim	Loop 2300 CLM05-3 (Claim Frequency Code) = “7” (Replacement)	Block 22 – Medicaid Resubmission Code Code = “7” (Replacement)
      Original Claim ID	Loop 2300 REF – Payer Claim Control Number REF01 = “F8” (Original Reference Number) REF02 = Original HMSA Claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID
      Reason for correction	Loop 2300 NTE – Claim Note Segment NTE01 = “ADD” NTE02 = text explaining reason for correction Optional – NTE segment at Loop 2400 line level if more space is needed.	Block 19 – Reserved For Local Use Text explaining reason for correction

UB-04 Claims

HMSA supports electronic claim resubmission and will uses the Frequency Code (last digit on the Type of Bill) to identify corrected claims or to void/cancel previously processed claims. Electronic submission of corrected claims is preferred to hard-copy paper resubmission. The following represents the NUBC frequency code values that can be submitted on the electronic and hard-copy Institutional claim.

1. Replacement Claims (Frequency code 7)

   A replacement claim is sent when an element of data on the claim was either not previously sent or needs to be corrected. Examples include dates of service and/or units. The following claim information must remain the same as the original claim.

   • Rendering and billing provider
   • Patient name
   • Payer name
   • Subscriber name and identifier
   • Statement covers period – from date

   If any of the above values differ from the original claim, void the original claim and submit a new claim.

   Do not file a claim if the amount of payment received or denial of services as billed on the claim is being disputed. Please submit a provider correspondence inquiry, claim reconsideration request, appeal or arbitration.

   Requirement	Electronic 837I Version 5010	Paper UB-04
   Indication of replacement or void claim	Loop 2300 CLM05-3 (Claim Frequency Code) = “7” (Replacement)	Form Locator 4 Last position of Type of Bill (Claim Frequency Code) = “7” (Replacement)
   Original claim ID	Loop 2300 REF – Payer Claim Control Number REF01 = “F8” (Original Reference Number) REF02 = Original HMSA Claim ID	Form Locator 64 – Document Control Number must contain Original HMSA Claim ID
   Reason for the correction	Loop 2300 HI – Condition Information HI01-1 = “BG” (Condition) HI01-2 = Valid Condition Code from the table below: “D0” (service dates) “D4” (ICD-diagnosis/procedure code) “D1” (charges) “D8” (Medicare primary) “D2” (rev code/HCPCS/HIPPS) “D9” (any other change) “D3” (subsequent interim PPS) “E0” (patient status) HI02-HI12 can be used to convey more than one condition code when necessary. When Condition Code = “D9”, Billing Note segment is also required: NTE – Billing Note Segment NTE01 = “ADD” NTE02 = Text explaining reason for correction	Form Locator 18-28 – Condition Code At least one valid value from the table below: “D0” (service dates) “D4” (ICD-diagnosis/procedure code) “D1” (charges) “D8” (Medicare primary) “D2” (rev code/HCPCS/HIPPS) “D9” (any other change) “D3” (subsequent interim PPS) “E0” (patient status) Form Locator 80 – Remarks When Condition Code = “D9”, include text explaining reason for correction.

2. Void/cancel claims (Frequency code 8)

   When identifying elements on the claim requiring correction, void the original claim and submit a new claim. A void claim contains all claim data exactly as submitted on the original claim, except the fields below:

   Requirement	Electronic 837I Version 5010	Paper UB-04
   Indication of replacement or void claim	Loop 2300 CLM05-3 (Claim Frequency Code) = “8” (Void)	Form Locator 4 Last position of Type of Bill (Claim Frequency Code) = “8” (Void)
   Original claim ID	Loop 2300 REF – Payer Claim Control Number REF01 = “F8” (Original Reference Number) REF02 = Original HMSA Claim ID	Form Locator 64 – Document Control Number must contain Original HMSA Claim ID
   Reason for correction	Loop 2300 HI – Condition Information HI01-1 = “BG” (Condition) HI01-2 = Valid Condition Code from table below: “D5” (correct claim number or provider number) “D8” (Medicare primary) “D6” (recover duplicate payment or overpayment) “D9” (any other change) “D7” (Medicare secondary)   HI02-HI12 can be used to convey more than one condition code when necessary. When Condition Code = “D9”, Billing Note segment is also required: NTE – Billing Note Segment NTE01 = “ADD” NTE02 = Text explaining reason for correction	Form Locator 18-28 – Condition Code At least one valid value from the table below. “D5” (correct claim number or provider number) “D8” (Medicare primary) “D6” (recover duplicate payment or overpayment) “D9” (any other change) “D7” (Medicare secondary)   Form Locator 80 – Remarks. When Condition Code = “D9”, include text explaining reason for correction.

3. Claim Reconsideration Requests

   If you disagree with the amount of payment received or the denial of services as billed on the claim, do not resubmit the claim or file a claim tracer. Please submit a provider correspondence inquiry, fee inquiry or appeal.

   HMSA – QUEST Integration Operations

   P.O. Box 3520

   Honolulu, HI  96811-3520

   • QUEST Integration – Fee Reviews
   • QUEST Integration – Provider Reconsiderations, Grievances, and Appeals Process

Revision History