Resubmission of Claims (CMS-1500)

• Verifying Claim Status
• Resubmission Instructions: Partial denial due to request for attachments (e.g., operative notes, treatment plan, etc.)
• Resubmission Instructions: Partial denial requiring corrected claim information (e.g., incorrect diagnosis codes, add a modifier)
• Resubmission Instructions: Original claim was paid by HMSA or is in process
• Claim Reconsideration Requests

Verifying Claim Status

It is important to understand the status of your claims in order to resubmit them properly. 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. Additional claims will be denied as duplicate. If the additional claim was submitted to correct a suspended claim or attach documentation, the suspended claim needs to be voided first. 

In general, you may file a new claim when:

1. A claim was never billed.
2. A claim was submitted but rejected by Form 97 letter or CRTP.
3. A claim was denied entirely requesting information needed for processing (e.g. medical notes, other carrier payment report)

You must file a corrected claim when HMSA has processed and made any payment on your original claim.

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 when necessary, understand the correction that is required and ensure that the resubmitted claim is not denied as a duplicate. Please include all services rendered, including previously paid services, on any corrected claim. Please also remember that when submitting a corrected claim, you must ensure that your corrected claim contains a valid Member ID and Billing Provider Tax ID that match the original claim. If the Member ID or Billing Provider Tax ID need to be corrected, the procedure is to VOID the original claim (using frequency code 8) and to submit a new, clean claim using the correct Member ID and/or Billing Provider Tax ID.

Note: Electronic resubmissions of claims are preferred to hard-copy paper. However, the electronic resubmission cannot support electronic attachments at this time. For claims initially denied for primary carrier Explanation of Benefits, please resubmit electronically with the necessary data fields that represent the payment amount and member responsibility amount(s) reported by the primary payer.

1. Original claim was partially denied by HMSA

a. Partial denial due to request for attachments (e.g., operative notes, treatment plan, etc.)  NOTE: Any documentation received without a claim attached will not be processed. 

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: Box 22, Resubmission Indicator 7
• HMSA claim ID of claim being corrected: Box 22  
• Please note, when multiple resubmission claims are on file, use the ID of the most recent paid claim. Once a claim is corrected, it is replaced by the new claim and cannot be corrected again.
• Reason for the attachments: Box 19

Providers should not file another claim if the attachments have already been reviewed by a Medical Director or Medical Staff. 

EXAMPLE

b. Partial 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
• HMSA claim ID of claim being corrected
• Reason for the correction

EXAMPLE

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 review or an appeal.

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 or wrong provider must be canceled from HMSA's claims processing system. Do not submit a corrected claim with Resubmission Code 7 for these situations. Submit a void claim as soon as you 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 claim being voided. 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
• HMSA claim ID of claim being voided

EXAMPLE

b. Submit corrections to a paid claim

Electronic 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
• HMSA claim ID of claim to be corrected
• Reason for the correction

EXAMPLE

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 Resource Center for submitting a provider correspondence inquiry, fee inquiry or appeal:

• Provider correspondence inquiry
• Fee Reviews
• Appealing Processed Claims