As a reminder, there are specific guidelines in the IBC
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 2300, Reference CLM05-3 (Claim Frequency
Type Code);
- If CLM05-3 contains 5, 7, or 8, prior claim information
is required in Loop 2300 because it indicates that
a claim is a replacement or void to a previously
adjudicated claim.
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 Remittance
or Explanation of Benefits (EOB)*.
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 not an
EDI transaction available to return the requested
information.
For more information
For more information about electronic claim submission
guidelines, refer to the IBC HIPAA Transaction Standard
Companion Guide, available on the IBC Trading Partner
Business Center.
If you have questions about the requirements for
resubmitting electronic claims, please contact your
Network Coordinator.
*For migrated member claims, providers will receive a
Provider
Remittance/EOB. For non-migrated member claims, providers will
receive a Statement of Remittance.