Eastpointe Claims and Funding Services
Reversing vs Replacing vs Rebilling a Claim
Reversal Required when a claim, billed in error, is paid and the money needs to be refunded to Eastpointe. EXAMPLE: A claim is billed for the wrong Member and is paid. ACTION TO CORRECT: Submit a claim reversal. This will create a credit memo which will be applied to a later approved claim. HOW: Portal submission; submit a second claim (can copy original claim) and in block 22 on the CMS1500 select 20 -Reversal in the drop down and enter the Claim Header ID from the approved claim in the box marked Original REF. NO. On the UB04, the last digit of the bill type should be replaced with an 8 to denote a void and in box 64 the Claim Header ID from the approved claim should be entered. CMS1500 UB04
Replacement Required when a claim is paid but was submitted with incorrect data such as procedure code, place of service, units or site. EXAMPLE: A claim is billed for 1 unit when in reality 2 units of service were provided. ACTION TO TAKE: Submit a new claim as a replacement for the claim paid with the incorrect data. HOW: Portal submission; submit a new claim with the correct data elements and in block 22 on the CMS1500 select 10-Replacement in the drop down and enter the Claim Header ID from the incorrect/approved claim in the box marked Original REF. NO. On the UB04, the last digit of the bill type should be replaced with an 7 to denote a replacement and in box 64 the Claim Header ID from the incorrect/approved claim should be entered. The previous claim will be marked as void and a credit memo generated and applied to a later payment. The newly submitted claim information will be adjudicated in it’s place. CMS1500 UB04
Rebilling Required when a claim is submitted and denied. EXAMPLE: A claim is submitted and denied and the reason causing the denial has been corrected. The claim will need to be rebilled. **To ensure the additional billing time allowed for resubmitting denied claims, it is best practice to submit all denied claims as replacement claims.** HOW: Portal submission; resubmit the claim and in block 22 on the CMS1500 select 10- Replacement in the drop down and enter the Claim Header ID from the denied claim in the box marked Original REF. NO. On the UB04, the last digit of the bill type should be replaced with an 7 to denote a replacement and in box 64 the Claim Header ID from the denied claim should be entered. The claim will be reprocessed considering the corrections made since the previous billing. CMS1500 UB04
Denial Reasons in reference to replacement, reversal and resubmitted claims 93-invalid DCN or resubmission ref # • This is for replacement claims and reversals. The claim number entered for the original claim that the replacement claim/reversal claim is referencing is invalid. 94 – resubmitted claim DOS is after original claim submission date • This is for replacement claims. The original claim was submitted earlier than the DOS on the referenced claim. 95 – Resubmitted claim does not match with the reference claim • A replacement claim must match the original claim for 3 out of 6 criteria. The criteria are provider, member, service, place of service, date of service and principle diagnosis. 96 – referenced claim has already been resubmitted, multiple resubmissions not allowed • This is for replacement claims and reversals. The original claim being referenced has already been resubmitted. A claim header can only be resubmitted once.
Obtaining Claim Numbers for Replacement, Reversal or Resubmitting Denied Claims for claims submitted in Legacy system. Claims submitted to Avatar (prior to 5/4/15) • Claim header ID can be obtained by contacting Network Operations. 888-977-2160
AlphaMCS Denials Guide Is currently being updated by AlphaMCS Completion will be posted as a Portal Announcement
Claims & Billing Webpage www.eastpointe.net • For Provider Community • Medicaid 1915 b/c Waiver Information • Claims and Billing
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