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As a reminder, there are specific guidelines in the AmeriHealth versions of
the HIPAA Transaction Standard Companion Guide that providers must
follow when resubmitting a claim for an adjustment. In order for the adjustment
to occur, the following Loop ID/Reference segments must be populated
accordingly:
- Loop ID: 2300, Reference: CLM05-3 (Claim Frequency Type Code);
- If CLM05-3 contains 5, 7, or 8, prior claim information is required in the
following Segments are required in Loop 2300:
- ? REF ? Payer Claim Control Number (REF01 = F8 and AmeriHealth Claim
Number in REF02)
- ? NTE ? Billing Note (NTE01 = ADD and detailed description regarding
the adjustment in NTE02)
Claims resubmission
Claim Frequency Type Codes that tie to a "prior claim" or "finalized claim"
refer to a previous claim that has completed processing in the payer's system
and has produced a final paper/electronic Provider Explanation of Benefits
(professional) or Provider Remittance (facility).
Please note the following:
- Previous claims that are pending due to a request from the payer for
additional information are not considered a "prior claim" or "finalized
claim."
- An 837 professional claim transaction is not an appropriate response to a
payer's request for additional information. Rather, providers must follow the
instructions within the request for returning the additional information. At
this time, there is no EDI transaction available to return the requested
information.
For more information
For more information about electronic claim submission guidelines, refer to
the appropriate AmeriHealth HIPAA Transaction Standard Companion Guide,
available on the Trading Partner Business Center.
If you have questions about the requirements for resubmitting electronic
claims, please contact your Provider Partnership Associate or Network
Coordinator.
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