Denial vs Rejection

A Denial is a Claim that the Payer has adjudicated but is denying Payment on one or more Charges on the Claim.

• You have either received a Paper or Electronic Remittance with the denial.
• Denied Charges can be resubmitted as a Corrected or Replacement Claim.

A Rejection is a Claim that did not enter the Payer's Adjudication System.

• You received a System status that the Claim was either Rejected by the Clearinghouse or the Payer.
• You did not receive a Paper or Electronic Remittance for this Claim.
• A Rejected Claim cannot be sent as a Corrected or Replacement Claim since the Payer did not receive the Claim.
  

Claims that are being sent as Corrected/Replacement Claims should be marked to Rebill at the top of the Modify Charge screen.

• This changes the Claim Status to change to Ready for Submission/Resubmission.
  

Corrected/Replacement Claims

Designation of Corrected Claim and Delayed Reason Code can be sent on an ANSI (Electronic Claim).

Remember, If you have not received a denial on an ERA Remit or on a Paper EOB, do not use Replacement.

For Medicare: See Send Replacement Claim as Original

Replacement Claim/Auto-Populate with Corrected Claim

If you choose Replacement in the Claim dropdown or if you have the Insurance marked as Send Replacement Claim as Original, CORRECTED CLAIM, will auto-populate on the Claim in ANSI Loop 2300, NTE Segment.

1. From the Encounter Dashboard, select Modify Charge.

2. On the bottom portion of the Modify Charge screen, use the Claim dropdown to choose Original or Replacement.

The ICN number pulls from the most recent ERA payment, or can be manually added.

The Corrected Claim Note is added to the NTE segment in Loop 2300.

• Corrected Claim will be added if Replacement is chosen or if the Send Replacement Claim as Original checkbox is chosen on the Insurance.

There are some Payers, such as Medicare, that do not accept Replacement (7).

• For these Payers, all Claims must be designated as Original (1).
• On the Insurance in the Insurance Library, select the checkbox for Send Replacement Claim as Original, which will auto-populate, Corrected Claim, on the ANSI Loop 2300, NTE segment.
• See Send Corrected Claims to Payers that Only Support "Original" Claims

Delayed Reason Code

1. From the Encounter Dashboard, select Modify Charge.

2. Delayed Reason Code: Select the Lookup icon.
3. Select the Reason that the Claim is delayed.

• Most Payers accept 7 (Third Party Processing Delay) or 8 (Delay in Eligibility Determination)
• This populates ANSI Loop 2300.

4. Select Save [F2].

 Some payers do NOT accept ANSI-designated Replacement Claims and/or Delayed Reason Codes, others require them, contact individual Payers for their requirements. For example, Medicare never accepts Replacement.

Manually add the Corrected Claim Note to an Electronic Claim

If you want to enter a manual Note, it will take precedence over the auto-populated note and will show on the Claim.

1. On the Encounter Dashboard, select Modify Charge.

2. In the Claim panel, select the Lookup icon beside ANSI Field.

3. Select CLMNOTE from the dropdown.

4. On the ANSI Field Group popup screen, enter Corrected Claim in the Note field and any additional details, such as added 25 modifier.
5. Select Save [F2].

6. After necessary changes are made, select Save [F2] on the Modify Encounter screen.

  This action will set the Claims Status to Ready for Submission/Resubmission.

Manually add Corrected Claim in HCFA Box 19

• Selecting Replacement on the Modify Charge screen, will populate Corrected Claim in HCFA Box 19 automatically.

If Replacement is not selected on the Modify Charge screen, Corrected Claim can be added to the HCFA manually by entering it in the HCFA fields.

 Note: This ONLY affects HCFAs, there is no Box 19 for electronic Claims. Data entered on the Extra HCFA Information screen will override what would otherwise print 

1. On the Encounter Dashboard, select the HCFA fields link.

2. On the Extra HCFA Information screen, enter Corrected Claim in Box 19.

• Entering a value in the field will override existing information in the field.

• Example: If you have it set up to print the Taxonomy in Box 19, it will be overridden by manually entering Corrected Claim.

3. Select Save (F2).

Display "Corrected Claim" at the Procedure Line level

To display Corrected Claim at the Procedure Level in ANSI Loop 2400 NTE Segment, or on the HCFA Box 24 above the Procedure:

1. On the Encounter Dashboard, select Modify Charge.

2. Select the Procedure Line in the Procedures panel to modify.
3. In the Note field, type: Corrected Claim and any additional details.
4. Save(F2) to save the Procedure Line.

5. Selecting Replacement, puts a 7 in Loop 2300 and puts Corrected Claim in HCFA Box 19.
6. On the Modify Charge screen, select Save (F2).

Send a Voided Claim

Most Payers do not accept this as a means to Void a previously submitted Claim.

Check with the Payer before using Void on the Claim.

If the Payer accepts Voided Claims:

1. Select the Modify button on the Encounter Dashboard.
2. Select Void from the Claim dropdown on the Modify Charge screen.

• This will send a 3 in ANSI 2300 CLM05-3.

3. Select Save [F2].