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Insurance Billing 8: Resubmissions

  1. Insurance Billing Training (US)
  2. Insurance Billing 8: Resubmissions

    3. 7 min read
    Practice Plan Thrive Plan

This is lesson 8 of 9 in the US Insurance Billing training:

Billing Lesson Lesson Complete
Patient Insurance 🥳
Adding Billing Codes to a Visit 🥳
Managing Insurance and Patient Responsibility on a Visit 🥳
Claim Submission Folders 🥳
Claim Submission 🥳
Managing Rejections 🥳
Posting Insurer Responses 🥳
Resubmissions ✍️
Accounts Receivable ☐

Rejections vs. denials

  • Rejection: The clearinghouse (before the claim reached the insurer) or the insurer’s front end (before adjudication) found an issue and stopped the claim. Fix: Correct the claim and resubmit it as an Original Claim.

  • Denial: The insurer processed the claim, then denied all or part of it. The insurer response includes a claim control number and a denial reason. Fix: Submit a Replacement Claim or appeal, based on the insurer’s guidelines. Check out our guide on Resubmissions.

When an insurer denies a claim, find the denial reason, correct the claim, and resubmit it with a resubmission code and the Claim Control Number.

Step 1: Understand the Denial

Interpreting the denial reason is usually the trickiest part of the process. Each insurer has its own process for receiving resubmissions.

Where to find the denial reason:

  • Paper EOB: The denial reason is listed on the EOB.

  • Electronic response (ERA): Go to the Remittances folder and check the Messages column of the response.

The Claim Response window for an ERA, showing the Claim Control Number and the Messages column with adjustment reasons for each billing code

Step 2: Correct the Claim

Correct the claim in Jane so the insurer can process it when you resubmit. The changes depend on the denial reason.

For example, you might need to adjust the billing codes on the patient’s visit.

đŸ“£ Heads up: If the patient paid their patient responsibility at the time of service and you change the invoice (for example, edit a billing code), click Update Invoices after making your changes. This makes sure the changes appear on your resubmission.

The Insurance section of a purchase with Allow Editing turned on and the orange Update Invoices button shown after changes were made

Step 3: Move the Claim to the Draft or Unsubmitted Folder

Jane only generates submissions for claims in the Draft or Unsubmitted folders. Move the corrected claim to one of these folders before you resubmit.

You can mark a claim as Draft or Unsubmitted from a few places in Jane. From a Claim Submission folder (such as Submitted or Rejected), use the Claim Summary panel:

  1. Click View next to the claim.
  2. Click the circle drop-down at the top of the Claim Summary panel.
  3. Select Mark as Draft or Mark as Unsubmitted.

The Claim Summary panel in the Submitted folder with the circle drop-down open, showing the Mark as Draft and Mark as Unsubmitted options

Step 4: Resubmit with a Resubmission Code and Claim Control Number

A resubmission needs a resubmission code and the Claim Control Number from the insurer response. The Claim Control Number lets the insurer connect your resubmission to the original submission in their system.

When Jane recognizes that you’ve submitted a claim before, your resubmission options appear in the Pre-Submission Checklist.

The Submit Claims page showing the Resubmission / Correction Code drop-down set to Original Claim and the Add button under Claim Control Number

Choose a Resubmission Code

đŸ“£ Heads up: Don’t use Corrected Claim (6). The code is available in the list, but your clearinghouse will likely reject it.

  1. Select the resubmission code the insurer requires:
    • Replacement of Prior Claim (7): Use for denied claims.
    • Void / Cancel Prior Claim (8): Use for voided claims.

The Resubmission / Correction Code drop-down open, showing Original Claim, Corrected Claim (6), Replacement of Prior Claim (7), and Void / Cancel Prior Claim (8)

Add the Claim Control Number

Some insurers call the Claim Control Number an ICN (Internal Control Number) or a reference number.

  1. Click the blue Add button in the Claim Control Number section.
  2. Enter the Claim Control Number from the insurer response in the field that appears. Use the unique identifier for the patient’s specific date of service.
  3. Select the checkbox to save the Claim Control Number to the submission.

The Resubmission / Correction Code set to Replacement of Prior Claim (7) with a Claim Control Number entered and the checkmark button beside it

Your claim is now ready to resubmit!

Continue to Insurance Billing 9: Accounts Receivable

đŸ“˜ Continue learning the insurance billing workflow in Insurance Billing 9: Accounts Receivable