How to Submit Corrected CMS-1500 & UB-04 Claims: A Step-by-Step Guide

Navigating the complexities of medical billing requires precision, especially when it comes to correcting and resubmitting claims. Errors can lead to delays in reimbursement or outright denials, impacting your organization’s revenue cycle. This comprehensive guide provides step-by-step instructions for submitting corrected CMS-1500 and UB-04 claims, ensuring you understand the necessary adjustments for timely and accurate processing. We’ll cover CMS-1500 resubmission codes, UB-04 corrected bill types, common claim adjustment reasons, and best practices for resubmitting denied claims.

Understanding Corrected Claims: Why Resubmission Matters

A corrected claim is a resubmission of a previously submitted claim that contained errors or omissions. Unlike initial claims, corrected claims require specific indicators to inform the payer that it’s an adjustment to a prior submission. Proper correction is vital for:

• Ensuring accurate patient billing and financial records.
• Minimizing payment delays and maximizing reimbursement.
• Maintaining compliance with payer guidelines and regulatory standards.
• Avoiding potential audit triggers related to inconsistent claim submissions.

Common Reasons for Claim Adjustments

Claims often require correction due to a variety of errors. Understanding these common claim adjustment reasons can help prevent future mistakes and streamline the correction process:

• Incorrect Diagnosis Codes (ICD-10): Errors in the primary or secondary diagnosis codes that do not accurately reflect the patient’s condition or medical necessity for services.
• Incorrect Procedure Codes (CPT/HCPCS): Mistakes in the codes representing the services provided, including incorrect codes, missing codes, or issues with modifier application.
• Patient Demographics and Insurance Information: Typographical errors in patient names, dates of birth, policy numbers, group numbers, or inaccurate subscriber information.
• Modifier Errors: Incorrect or missing CPT/HCPCS modifiers that clarify the service performed or the circumstances under which it was performed.
• Missed Charges: Services rendered that were not initially included on the original claim, requiring an addition to the total charges.
• Duplicate Claims: Accidental submission of the same claim multiple times, which needs to be identified and one submission marked for correction/void.
• Provider Information Errors: Incorrect NPI, tax ID, or facility address.

Step-by-Step: Correcting and Resubmitting CMS-1500 Claims

The CMS-1500 form is used for professional (physician and non-institutional) claims. When resubmitting a corrected CMS-1500 claim, specific boxes must be updated to ensure it’s processed as a correction, not a new claim.

Key Fields for CMS-1500 Resubmission

• Box 22 (Resubmission Code): This is crucial.
  • Enter the appropriate CMS-1500 resubmission code. Common codes include:
    • 7 (Replacement of Prior Claim): Used when correcting and replacing a claim that was previously processed.
    • 8 (Void/Cancel of Prior Claim): Used to cancel a previously submitted and processed claim.
  • In the space to the right of the resubmission code, enter the Original Reference Number (ICN/DCN) provided by the payer for the original claim. This number links your corrected claim to the previous submission.
• Box 17b (NPI of Referring/Ordering Provider): If the NPI for a referring or ordering provider was incorrect, update it here.
• Boxes 19 or 23 (Prior Authorization Number): If a prior authorization number was missing or incorrect, update it here, or in Box 19 if additional comments are needed to explain the correction.
• Corrected Information: Make all necessary corrections to diagnosis codes (Box 21), procedure codes and modifiers (Box 24D), charges (Box 24F), and any other relevant demographic or service information.

Ensure you resubmit all original lines and charges, even those that were correct, along with the corrected or additional information. Hand-corrected claim re-submissions are generally not accepted; electronic resubmission is preferred.

Step-by-Step: Correcting and Resubmitting UB-04 Claims

The UB-04 (CMS-1450) form is used by institutional providers like hospitals, nursing facilities, and home health agencies. The most critical field for corrected UB-04 claims is the Bill Type.

Choosing the Correct UB-04 Bill Type: xx7 vs. xx5

The Bill Type, located in Box 4 of the UB-04, is a three-digit code that indicates the type of facility and the sequence of the bill. For corrected claims, the third digit is paramount:

• First Digit (Type of Facility): e.g., ‘1’ for Hospital, ‘2’ for Skilled Nursing Facility.
• Second Digit (Type of Care): e.g., ‘1’ for Inpatient, ‘3’ for Outpatient.
• Third Digit (Frequency Code): This digit indicates whether the bill is an original submission, a corrected claim, or a late charge.

For resubmitting denied claims or correcting a claim:

• Bill Type xx7 (Replacement of Prior Claim): This is the appropriate frequency code for submitting a corrected claim that replaces a previously submitted and processed claim. For example, ‘137’ for a corrected outpatient hospital claim. When using ‘xx7’, you must also include the original claim number (Document Control Number – DCN) in Box 64 (Prior Payment – DCN). This links your new submission to the original.
• Bill Type xx5 (Late Charge Claim): This code is specifically for submitting additional charges that were omitted from a finalized claim but pertain to the same billing period. Crucially, xx5 should generally NOT be used for correcting errors on a claim that requires resubmission of the entire claim. Using xx5 for a full correction can lead to confusion and further denials, as it implies only an addition, not a comprehensive adjustment.

Similar to the CMS-1500, when correcting UB-04 claims, resubmit all original lines and charges, along with the new or corrected information. Ensure all relevant fields, such as patient demographics, diagnosis codes (Box 66-67), procedure codes (Box 80), and revenue codes (Box 42), are accurately updated.

What to Expect After Resubmitting Denied Claims

After you submit your corrected claim, understanding the next steps is important for managing your revenue cycle.

• Reprocessing Timeline: Payers typically have their own processing timelines for corrected claims. While some may process within a few days, others can take several weeks, similar to initial claims. Always check the specific payer’s guidelines or online portal for estimated resubmitting denied claims reprocessing times.
• Payment Adjustments: If the corrected claim results in an adjustment (increase or decrease) to the original payment, you will receive an updated Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) detailing the changes. For overpayments, the payer may request a refund or offset future payments.
• What if the Corrected Claim is Denied Again? If your corrected claim is denied, carefully review the new denial reasons. It’s possible a new error was introduced, or the original correction was insufficient. This may require further investigation and potentially another corrected claim submission or an appeal, following the payer’s appeal process.

Navigating Payer-Specific Guidelines

While the general principles for corrected claim submissions (e.g., using frequency code ‘7’ for UB-04 or ‘7’/’8′ for CMS-1500 resubmission codes) are widespread, the exact requirements can vary significantly among different payers. Medicare, Medicaid, and various commercial insurers (e.g., Blue Cross Blue Shield, UnitedHealthcare, Aetna) often have their own specific rules, forms, and electronic submission portals.

It is imperative to always consult each payer’s official provider manual, website, or dedicated EDI Support line for the most accurate and up-to-date information regarding their corrected claim submission processes. These resources will detail specific box requirements, claim adjustment reason codes, and submission methods.

Frequently Asked Questions (FAQs) About Corrected Claim Submissions

Q: What is a CMS-1500 resubmission code?

A: A CMS-1500 resubmission code (found in Box 22) is a two-digit code that tells the payer that the claim being submitted is a correction or cancellation of a previously submitted claim. Common codes are ‘7’ for a replacement claim and ‘8’ for a void/cancel claim. It must be accompanied by the original claim’s reference number.

Q: How do I know if my UB-04 needs a corrected bill type?

A: Your UB-04 needs a corrected bill type if you are resubmitting a claim that had errors and was processed (or denied) by the payer. You would use a bill type ending in ‘7’ (e.g., 137 for outpatient hospital) to indicate it’s a “Replacement of Prior Claim.” If you are only adding late charges to a finalized claim without correcting other errors, a bill type ending in ‘5’ might be used, but this is less common for comprehensive corrections.

Q: What are common claim adjustment reasons?

A: Common claim adjustment reasons include incorrect diagnosis codes, procedure codes, patient demographics, missing or incorrect modifiers, missed charges, and duplicate submissions. Identifying the exact reason for the initial error is key to successful correction.

Q: How long does it take for a corrected claim to be processed?

A: The processing timeline for corrected claims varies by payer, but it typically ranges from a few days to several weeks. It’s advisable to check the specific payer’s provider manual or online portal for their estimated processing times for resubmitting denied claims.