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:

• HHIN Documents & Information
• Report to Provider
• Telephone inquiry
• Written inquiry

 

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:

• Provider correspondence inquiry
• Fee review
• Appealing processed claims