Claim denials occur for a variety of reasons. The payer ID may be incorrect, the authorization number for your client may be incorrect or there may be a modifier missing. The explanation of benefits (EOB) or the remittance advice (RA) you receive from your payer will provide you with the information needed to correct the EDI file.
Changes to schedules (start/end times, service type etc.) will require that the original invoice be deleted prior to making corrections. In this case, a new invoice will need to be created and a new EDI file generated. Please follow the steps outlined in the Generate EDI File for Billing article.
Many State and MCO payers will allow you to resubmit the corrected claim in its entirety. Changes to client/payer information can be completed without reversing any billing.
Once you have made the required corrections, please follow these steps:
Navigate to the Accounting Module and select View EDI
Select Generated EDI and adjust the filters to search for the file that needs to be resubmitted.
Click on the Green EDI Icon to open up the file generation screen
To generate a corrected claim, select the green Regenerate button at the top of the screen. This will download an updated EDI file that you can then submit to your payer.
If you need to submit a corrected claim for only one client, you can find the client in the list and click on regenerate at the client level.
Some payers require that a replacement claim be submitted with the original claim number or ICN number referenced. Some manual updating is required in this instance. To generate a replacement claim and add the required fields, please follow the below steps.
Select Regenerate Replacement. This will download a file that contains some additional information. Open the file in Notepad to view.
Below the client information, you will see a line that begins with CLM. 7 indicates that this file is a replacement, if you need to Void a previously submitted claim, you will need to change the 7 to an 8.
On your Explanation of Benefits or Remittance Advice, you should be able to locate the Claim ID, Claim Reference # or ICN. This number needs to be added to the regenerated EDI file in the below field. Add the number between the * and ~.
Save your changes and proceed with submitting the replacement claim as you normally would.
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