Sending Replacement & Cancellation Claims

Follow

PURPOSE: The following are instructions for submitting claims intended to correct, replace, or cancel a previous claim.

________________________________________________________________________________________________________________

Contents

General Concepts

What is a Replacement or Cancellation Claim?

Is a Replacement/Cancellation Necessary for Every Error?

Which One do I Choose: Replacement or Cancellation?

Steps for UHINt Users

________________________________________________________________________________________________________________

General Concepts

What is a Replacement or Cancellation Claim?

When a claim is sent for the first time, it is considered an “original” claim. When a mistake is made, it may be necessary to replace or cancel the original claim.

To create an electronic Replacement or Cancellation claim, you need two elements:

  1. You must mark the claim as a Replacement or Cancellation. There will be a setting in your software to accomplish this. Marking the claim as “Replacement” or “Cancellation” will let the payer know that this new claim is not a duplicate.
  2. You must include the original claim’s reference number. This number is assigned by the payer when they receive the claim. It is unique, and helps the payer identify the claim in their system. The payer will give you this number (also sometimes called a Payer Claim Control Number, ICN, or TCN) on the reports they send back. Putting this tracking number in your Replacement or Cancellation claim will ensure the payer replaces or cancels the correct original claim.

 

Is a Replacement/Cancellation Necessary for Every Error?

No. If the error in the file caused the claim to reject within the first few days of processing (on report types 837, 999, or 277CA), that claim is no longer active in the payer’s system. Any changes can be sent on a new, original claim.

If the claim is still actively processing or has paid, it will be necessary to send a Replacement or Cancellation claim to make changes.

If the original claim completed processing but paid $0.00, your next step depends on the individual payer. Some payers require Replacement or Cancellation claims to make changes, while others allow changes on new original submissions (as long as paid amount was $0.00). If you are unsure, check with the payer.

Which One do I Choose: Replacement or Cancellation?

  • Replacement: These are also called “corrected” claims. Select this option when the error does NOT affect the identity of a patient or provider. For example, incorrect billed amounts, number of units, or diagnosis codes can be handled with a Replacement claim.
  • Cancellation: Cancellations should be used when the error DOES affect the identity of the patient or provider. For example, an incorrect patient name and ID will affect the wrong patient’s benefits. Cancelling the claim will reset any incorrect benefit/financial effects from the original claim. Once the cancellation is complete, you can then submit a new original claim with the correct identity.

 

Steps for UHINt Users

The steps below describe how to submit a Replacement or Cancellation claim in the UHINt 2.6 software.

  1. Locate the payer’s reference/control number for the original claim. You can find this number on the 835 or EOB, and in some cases in the 277CA. It may be labeled as an ICN, TCN, Payer Claim Number, or something similar.
    • Examples:

mceclip0.pngmceclip1.png

  1. Open UHINt and navigate to the claim entry screen normally.
  2. Mark the Bill Type as either Replacement of Prior Claim or Cancel of Prior Claim, as appropriate.
    • Professional claims: you will find Bill Type in the upper-left corner.

mceclip4.png

    • Institutional claims: Use the Bill Type field (box 4). In institutional claims, the status of original, replacement, or cancellation is controlled by the third digit in the bill type code.
      • 3rd digit = 7: Replacement of Prior Claim (Ex: 247)
      • 3rd digit = 8: Cancel of Prior Claim (Ex: 248)
    • Dental claims: you will find Bill Type in the upper-left corner.
  1. Enter the payer reference number into the claim.
    • Professional claims: enter the number into box 22, Original Ref No.mceclip6.png
    • Institutional claims: enter the number into box 37, Original Payer Assigned Claim#.mceclip8.png
    • Dental claims: you will find Bill Type in the upper-left corner.
  2. Enter the rest of your claim normally.
    • Replacement claims: remember that the original claim will be completely replaced by this new replacement claim. All previous information and payments will be replaced by the contents of this claim. So, make sure this replacement claim contains ALL the details and amounts you want to be on file.
      • Example: In the original claim, you billed for 1 unit ($100) instead of 2 units ($200). You were paid $100 for the single unit. When sending a replacement claim, you would enter the full 2 units ($200).
    • Cancellation claims: you will need to re-create the original claim. Sending it as a cancellation will void the original claim in the payer’s system. You may then create a new, original claim with the correct information.

 

The information herein is the property of UHIN, and is intended for the educational and training purposes of UHIN members only.

 

0 out of 0 found this helpful

Comments

0 comments

Article is closed for comments.