Verifying Claim Status and Resubmission of Processed Claims (CMS-1500)

Verifying Claim Status

HMSA supports electronic requests for claim status using the HIPAA Standard X12N 276/277 Claim Status Request/Response transactions. The claim status request/response transaction is supported in both real-time and batch submission modes and is the preferred method of receiving routine claim status inquiries. Please contact HMSA's EDI Support Center for assistance using the 276/277 transaction.

In addition, providers can verify a submitted claim's status in a variety of ways:

Providers should monitor the claims they filed to verify their claims were received by HMSA and do not need a follow up. Providers may contact HMSA if there is an unusual delay of more than 30 days from the date the claim was submitted. Do not submit another claim if the submitted claim can be found on HHIN or in the Report to Provider – Claims in Process section. Duplicate claim submission will unnecessarily increase claim volume and can further delay processing.

Dual Member Coordination of Benefits (Two HMSA Plans)

When HMSA members have coverage under more than one HMSA plan, the claims processing system will coordinate benefits automatically when the plans are linked properly. The secondary claim usually processes one week after the primary claim is processed. Providers should inquire with HMSA if:

More than one week has passed and
The secondary claim does not reflect on the Claims In Process section in the Report to Provider

This will allow for HMSA to verify that the plans are linked properly.

Do not submit a secondary claim if a primary claim was already submitted. Claims submitted either electronically or hard copy with HMSA primary payment information will normally result in a duplicate claim denial.

For providers that receive the 835 electronic remittance transaction, the primary claim will reflect CLP02 = "19" (Processed as Primary, Forwarded to Additional Payer(s)) when the primary claim is linked to process automatically under the secondary plan.

Resubmissions and Corrections to Previously Processed Claims

Corrections may be needed for claims that have already been processed by HMSA. It is important to file the corrected claim according to the instructions below to ensure that HMSA can identify the original claim, understand the correction that is required and ensure that the resubmitted claim is not denied as a duplicate.

Note: Electronic resubmissions of corrected claims are preferred to hard-copy paper resubmissions. However, the electronic resubmission cannot support attachments such as operative notes or other carrier Explanation of Benefits.

1. Original claim was denied or partially denied by HMSA and

a. Denial due to request for attachments (e.g., operative notes, primary carrier EOB)

Must be submitted on paper - Complete a duplicate of the previously processed claim and add the information below. Claims that are submitted without the information below will be returned or denied as duplicates:

Indication that the claim is a replacement claim
Original HMSA claim ID
Reason for the attachments

EXAMPLE:

Requirement	Paper CMS-1500
Indication of replacement claim	Block 22 – Medicaid Resubmission Code Code = "7" (Replacement)
Original HMSA claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID
Reason for the correction	Block 19 – Reserved For Local Use Include text explaining reason for attachments (e.g. op notes, EOB)

Providers should not file another claim if the claim filed with attachments has already been reviewed by a Medical Director or Medical Staff. In order to dispute the outcome of a claim reviewed by Medical Staff, please refer to instructions on submitting a provider correspondence inquiry, fee inquiry, or an appeal.

b. Denial requiring corrected claim information (e.g., incorrect diagnosis codes, add a modifier)

Electronic resubmission is preferred to paper claim - Submit a claim with the corrected claim information and all the correct services originally billed. Corrected claims that are submitted without the below information will be returned or denied as a duplicate:

Indication that the claim is a replacement claim
Original HMSA claim ID
Reason for the correction

EXAMPLE

Requirement	Electronic 837P version 5010 (Preferred)	Paper CMS-1500
Indication of replacement claim	Loop 2300 CLM05-3 (Claim Frequency Code) = "7" (Replacement)	Block 22 – Medicaid Resubmission Code Code = "7" (Replacement)
Original HMSA claim ID	Loop 2300 REF - Payer Claim Control Number REF01 = "F8" (Original Reference Number) REF02 = Original HMSA Claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID
Reason for correction	Loop 2300 NTE - Claim Note Segment NTE01 = "ADD" NTE02 = text explaining reason for correction Optional - NTE segment at Loop 2400 line level if more space is needed.	Block 19 – Reserved For Local Use Include text explaining reason for correction

Do not file another claim if the amount of payment received or denial of services as billed on the claim is being disputed. Refer to the instructions on submitting a provider correspondence inquiry, fee inquiry or an appeal.

Note: Outpatient lab claims correcting previously billed diagnosis codes must include documentation of the corrected diagnosis codes from the physician that ordered the lab test(s). Attach the Additional DX Form signed by the ordering physician to the corrected claim.

2. Original claim was paid by HMSA or is in process

There are two ways to correct claims that were already paid by HMSA or are in process:

Void the claim that is paid or in process and submit an entirely new claim
Submit corrections to a paid claim

a. Void/cancel a paid or in process claim

Electronic resubmission is preferred to paper claim - Claims that were filed with HMSA in error or filed under the wrong patient may be canceled from HMSA's claims processing system. To do this, a provider should submit a void claim as soon as they become aware of the error, rather than wait for the claim to be paid or denied. The void claim must contain the exact claim data as submitted on the original claim. Void claims that are submitted without the information fields below will be returned or denied as duplicates:

Indication that the claim is a void claim
Original HMSA claim ID

EXAMPLE

Requirement

Electronic 837P version 5010 (Preferred)

Paper CMS-1500

Indication of void claim

Loop 2300
CLM05-3 (Claim Frequency Code) = "8" (Void)

Block 22 – Medicaid Resubmission Code

Code = "8" (Void)

Original HMSA claim

Loop 2300
REF - Payer Claim Control Number
REF01 = "F8" (Original Reference Number)
REF02 = Original HMSA Claim ID

Block 22 – Medicaid Resubmission Code

Original Ref. No. must contain Original HMSA Claim ID

A new claim can be submitted once the void claim is processed. The new claim will not be considered a duplicate to the original claim and can be filed as if no previous claim was ever submitted.

b. Submit corrections to a paid claim

Electric resubmission is preferred to paper claim - Submit a claim with the corrected claim information and the correct services originally billed. Corrected claims that are submitted without the information below will be returned or denied as duplicate claims:

Additional or corrected claim data, including those billed previously and paid correctly on the original claim
Indication that the claim is a replacement claim
Original HMSA claim ID
Reason for the correction

EXAMPLE

Requirement	Electronic 837P version 5010 (Preferred)	Paper CMS-1500
Indication of the replacement claim	Loop 2300 CLM05-3 (Claim Frequency Code) = "7" (Replacement)	Block 22 – Medicaid Resubmission Code Code = "7" (Replacement)
Original HMSA claim ID	Loop 2300 REF - Payer Claim Control Number REF01 = "F8" (Original Reference Number) REF02 = Original HMSA Claim ID	Block 22 – Medicaid Resubmission Code Original Ref. No. must contain Original HMSA Claim ID
Reason for the correction	Loop 2300 NTE - Claim Note Segment NTE01 = "ADD" NTE02 = text explaining reason for correction Optional - NTE segment at Loop 2400 line level if more space is needed.	Block 19 – Reserved For Local Use Text explaining reason for correction

Providers should not file another claim if the amount of payment received or denial of services as billed on the claim is being disputed. Refer to the instructions on submitting a provider correspondence inquiry, fee inquiry or an appeal.

Claim Reconsideration Requests

If a provider disagrees with the amount of payment received or denial of services as billed on the claim, they should not resubmit the claim or file a claim tracer. Refer to the instructions in the Provider E-Library for submitting a provider correspondence inquiry, fee inquiry or appeal:


Rev#:	Date:	Nature of Change:
2.0	03/16/2007	This document consolidates versions for multiple provider types into a single document.
2.1	05/04/2012	Removed: "Providers often find it necessary to resubmit a claim. Claims are resubmitted for a variety of valid reasons. For example: Payment may not have been made under the secondary coverage of a member who has two HMSA plans. The claim was processed, but the provider believes one of the procedures should have been paid at a higher eligible charge due to an unusual circumstance. A claim for an office visit and a lab test was processed. The office visit was paid, but the lab test was not because the provider did not list the medical condition for which the service was performed as a secondary diagnosis. The provider submitted a claim five weeks earlier and has not received payment. When the provider checked the "Claims in Process" sheet of the provider's last Report to Provider the claim was not listed. In addition, when the provider checked online with the Hawaii Healthcare Information Network (HHIN), the claim was not found. How to Resubmit a Claim Resubmissions must be prepared so that HMSA can easily identify and resolve the specific issue. If the claim does not indicate why it is being resubmitted, it will be returned to the provider, without having been entered into HMSA's claims processing system. Please prepare a resubmission by doing the following: I. Resubmitting for secondary plan benefits Complete a duplicate of the original claim using the same HMSA member ID number previously used. Include information about the secondary plan in blocks 9 through 9d of the CMS 1500 claim form. (Be sure to mark "yes" in block 11d.) Do not include information about the primary HMSA payment. (Z9014 may only be used when another health plan is the primary plan. It may not be used to represent payment by an HMSA plan.) Mark the top of the CMS 1500 claim form resubmission and include the reason for the resubmission, as shown in the example below." and also removed all of the examples (1-4).
2.2	05/07/2012	Removed: "II. Resubmitting for payment review Complete a duplicate of the previously processed claim. Attach an operative report, clinical notes or other documentation that supports your request for additional payment. Mark the top of the CMS 1500 claim form resubmission and include the reason for the resubmission, as shown in the example below. III. Resubmitting a corrected claim Complete a corrected claim, adding the secondary diagnosis or correcting the inaccurate information on the original claim. Do not submit handwritten notes on a copy of your Report to Provider to correct a claims filing error. Because each claim is a legal document, HMSA cannot change essential information (e.g., a diagnosis) on a claim. We must have a corrected claim form for reprocessing. Mark the top of the CMS 1500 claim form resubmission and include the reason for the resubmission, as shown in the example below. IV. Resubmitting a claim that has not been processed If a claim was submitted and more than 30 days have passed, the provider may resubmit the claim as a tracer. (If the claim is listed on the Claims in Process page, do not submit a tracer. If more than 30 days have passed since you submitted the claim, you may call a Provider Teleservice Representative to inquire about the delay.) Please follow the following steps when submitting a tracer: Check your Report to Provider for the past few weeks and verify that the claim is not shown on the Claims in Process page. If you have access to the Hawaii Healthcare Information Network (HHIN), you also may check online to verify whether the claim has been received. If the claim is not listed on the Claims in Process page, complete a duplicate claim. Mark the top of the CMS 1500 claim form resubmission or tracer and include the reason for the resubmission, as shown in the example below. V. Resubmitting a claim for another reason If you are resubmitting a claim for a reason other than those given in the preceding examples, please follow these basic steps: Complete the claim. Mark the top of the CMS 1500 claim form resubmission and include the reason for the resubmission. If the reason for the resubmission is not given, the claim will be returned to you unprocessed. Note: Do not use a marker to highlight corrections on the claim form as HMSA's scanning equipment cannot read highlighted characters. If you wish, you may place a check mark or asterisk in the margin next to the corrected item." also changed Title of document from "Resubmissions and Tracers" to "Verifying Claim Status and Resubmission of Processed Claims (CMS-1500)"
2.3	05/10/2012	New content replaced what was removed.
2.4	09/13/2012	Added: "for assistance using the 276/277 transaction" to the end of the first paragraph, also added "For providers that receive the 835 electronic remittance transaction, the primary claim will reflect CLP02 = "19" (Processed as Primary, Forwarded to Additional Payer(s)) when the primary claim is linked to process automatically under the secondary plan." and "However, the electronic resubmission cannot support attachments such as operative notes or other carrier Explanation of Benefits.", "Providers should not file another claim if the claim filed with attachments has already been reviewed by a Medical Director or Medical Staff. In order to dispute outcome of claim reviewed by Medical Staff, please refer to instructions on submitting a provider correspondence inquiry, fee inquiry, or an appeal.", and removed "HMSA supports the electronic submission of void claims" and also removed "HMSA is not able to support electronic attachments at the present time so attachments must be submitted hard copy."

Latest Revision:

09/13/2012