Resubmitting Billing Claims

The goal of this page is to provide a guide for processing denied claims effectively. The goal of resubmission is to rectify errors or discrepancies that result in the denial of a claim, ensuring accurate processing and reimbursement. 

Resubmission is necessary when:

• Essential information such as pre-certification IDs or procedural codes are incorrect or missing.

• Claims exceed allowed units or plan limits.

• Denials occur due to coding errors, lack of authorization, or eligibility issues.

During resubmission, it's crucial to:

• Verify and correct any inaccurate or incomplete information.

• Adjust unit counts or documentation to comply with payer guidelines.

• Address specific denial reasons such as coding errors or lack of authorization promptly.

If a claim is denied, follow the steps below to resubmit:

1. Start by navigating to Billing and selecting Batches. 
   

2. Select the eye icon to open the desired batch.

       

   3. Locate the claim in the claims tab which can be found inside of a batch. 

 4. Use the filter to sort for claims in To-Review status.

5. Find and select the claim you wish to process again. 

6. After initial review of rejection, you need to determine which claims need to be resubmitted. 

• Depending on the rejection reasons provided in the 835 file, take appropriate actions to address each issue. This may involve correcting errors in the original claim, providing additional documentation, or making adjustments as required. 

7. Prepare Resubmission Data: Once you've addressed the rejection issues, prepare the data for resubmission. This may involve creating new claim files or modifying existing ones to reflect the necessary changes. Here is the article on Creating a Batch for your reference: Creating a Batch?

8. Submit Resubmissions: In the claims tab select a claim to resubmit, then select Resubmit.

9. The resubmit window will open. All fields are optional. 

Fields:

Status dropdown options: select the correct status for this re-submission
- Original: the Payer did not receive the claim draft
- Replacement: change was made to claim draft 
- Void: there was an issue with the claim amount, or the Payer has requested a different recoupment amount

Resubmission reason: enter the reason you are re-processing this claim.

ICN/PCN Selection: select this checkbox to use the original claim’s ICN number in the resubmitted X12 message. The ICN is the claim number in the payer system (you can find it in the payer portal). Use this if the payer already has the claim in their system.

Payer Claim Number (ICN): enter a new ICN number here if you have not received a response from the payer.

10. Select resubmit to resubmit the claim. 

A pop-up message will show resubmitting process status.
 

11. On the Transactions tab, the claim will be found with the corresponding status. A new claim will be created and the original claim changed to "Errored" status.

Here are the definitions of claim status terms:

Filters	Function
All	all claims that are in the batch
Draft without exceptions	claims in draft form that are not yet submitted
Draft with exceptions	claims with billing exceptions in draft form not yet submitted
Sent	claims that have been sent for payment
Errored	claims that have been previously submitted but need to be revised before resubmitting
To review	claims that need to be reviewed before re-submitting; there is an action that needs to be taken
Processed	claims that have been submitted for payment and the clearinghouse has received the claim
Balanced	claims that were paid
Payment-in-progress	claims submitted awaiting payment; a message has been received from the clearinghouse that the payer has received the claim