Providers can electronically resolve a claim denial or incorrect payment for 837I (Institutional) and 837P (Professional) electronic claims. By resubmitting the claim with either frequency type code “7” (replacement of prior claim) or “8” (void/cancel of prior claim), there is no longer a need to adjust claims using paper Claims Inquiry Forms (CIFs) or Appeal Forms with accompanying Remittance Advice Details (RADs) to show proof of previous claim payment or denial. Electronic claim resubmission is not available for pharmacy claims.
The ANSI X12 v.5010 837 electronic transactions claim format allows a provider to initiate changes to already-adjudicated claims. The 837 Implementation Guides refer to the National Uniform Billing Data Element Specifications Loop 2300 CLM05-3 for explanation and usage. In the 837 formats, the codes are called “claim frequency codes.”
Replacement and void claims can be sent in the same batch as new claims.
Electronic replacement claims must be submitted within six months of the previous claim payment or denial. Providers may submit an electronic follow-up claim even if the original was a paper claim. Claims for which a CIF or appeal are already in progress must not be electronically resubmitted. Claims for which a CIF or appeal is in progress will be denied.
The following chart outlines the use of codes “7” and “8.”
Frequency Type Code ‘7’
Electronic allied health, long term care, medical services, obstetric, outpatient and vision care claims resubmitted with Frequency Type code “7” (replacement claim):
- Are used to modify only one claim line. They cannot be used to replace multiple original claim lines.
- A separate replacement claim transaction must be performed for each claim line being replaced. For example, to replace all five lines of an outpatient claim, the submitter must submit five separate transactions.
- Must contain corrected information for the original claim.
- Must include the 13-digit Claim Control Number (CCN) from the original paid claim. For the claim to be considered for full reimbursement, the RAD date for the previous claim payment or denial must be within six months of the date the replacement claim was submitted.
Electronic inpatient claims resubmitted with Frequency Type code “7” (replacement claim):
- Replace the entire inpatient care claim.
|Claim Frequency Code/Definition
Replacement of Prior Claim
|Use to replace a claim line or entire claim in an already adjudicated paid or denied claim (see following instructions per claim type)
||File the claim line or entire electronic claim including all services for which reconsideration is requested
||Medi-Cal will adjust the original claim. The corrections submitted will be reflected on the 835 Transaction and/or paper Remittance Advice Details (RAD) and other standard claim response vehicles
Void/Cancel of Prior Claim
|Use to eliminate an already adjudicated claim for a specific provider, recipient and date of service (see following instructions per claim type)
||File the claim electronically and include all claims data and charges that were on the original claim
||Medi-Cal will void the original claim from history based on request, which will be reflected on the 835 Transaction and/or paper RAD and other standard claim response vehicles
Frequency Type Code ‘8’
Electronic long term care, medical services, outpatient and vision care claims resubmitted with Frequency Type code “8,” (void/cancel of prior claim):
- Must include the 13-digit CCN from the original paid claim.
- Serve as a full void for one claim line only. Multiple original claim lines cannot be voided with one void claim transaction.
- A separate void claim transaction must be performed for each claim line being voided. For example, to void all five lines of an outpatient claim, the submitter must submit five separate transactions.
Electronic inpatient claims resubmitted with Frequency Type code “8” (void/cancel of prior claim):
- Void the entire inpatient care claim.
Errors to Avoid
Providers should pay attention to the instructions above that certain claim types can replace or void one claim line only. Additionally, the CCN of the original claim is the proper information to insert in the REF segment.
Correct CCN for Crossover Claims
Providers resubmitting a Medicare to Medi-Cal crossover claim should take care to enter the CCN from the Medi-Cal claim they are resubmitting and not the CCN from the Medicare claim.
Attachments required with the initial claim submission are required for replacement claim submissions. Copies of claims initially submitted on paper are not needed. Information from the paper claim will already have been keyed into the claims processing system.
No attachments are required when voiding a claim.
Information about submitting attachments for electronic claims is available in the Billing Instructions: Acceptable Claims, Attachments and ASC X12N 835 v.5010 Transactions section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual, specifically under the following headings:
- “Supporting Documentation – Attachments”
- “Attachment Control Form: Required and Optional Fields”
- “Attachment Control Form (ACF) Guidelines”
Associated RAD Code and Correlation Table Update
The following Remittance Advice Details (RAD) message has been added in the Part 1, RAD Repository, provider manual section to help providers reconcile claims submitted using claim frequency code “7.” (The claim frequency code is the third digit of the “Type of Bill” Code.)
||Computer Media Claims (CMC) replacement submitted after six months of referred claim Remittance Advice Details (RAD) is not payable
If the initial adjudicated claim was subject to a reimbursement reduction due to late claim submission, then reimbursement for the resubmitted claim also will be reduced.
Providers may wish to save a copy of this article for future reference.