If you’re using Jane’s EDI feature to submit to a clearinghouse and you need some help resubmitting corrected claims, then please read on!
What To Do If You Encounter a Rejected Claim
If you have received a rejection from the clearinghouse that you’re using to submit your claims, or from one of the payers that you bill, then you’ll likely need to create a new EDI file that you can use for resubmission.
Scenario 1: Receiving a Rejection From Your Clearinghouse
If you’ve received a rejection from your clearinghouse (meaning the claim never made it to the insurance company), then you can simply make your corrections in Jane (i.e. fixing an invalid combination of billing codes), move the claim back to the Unsubmitted Folder, and produce a new EDI file for that date of service. You’ll then need to download your new EDI file and upload it to your clearinghouse for submission.
There are a few different areas in Jane where you can mark a claim as unsubmitted. If you’re in Billing > Submitted Claims, you can select the rejected claim or claims, and mark them as unsubmitted.
After marking your claim as unsubmitted, you will need to make your required changes. You can head to your patient’s purchase if you need to adjust the codes, or to the patient’s claim if you need to update their policy information. If you aren’t sure where to make your changes, you can always reach out to our support team!
Pro tip: If the patient paid for a portion of the visit at the time of service (i.e. a co pay) and you need to make some changes to the invoice (i.e. change the order of diagnosis codes, or edit a billing code) before generating your resubmission, then make sure that you Update the Invoices after making your changes so they are reflected on your resubmission.
If you’re having trouble understanding why your clearinghouse has rejected a claim, there should be a reason or reason code included within the rejection. If you share the provided rejection reasons with our team, we’d be happy to show you where you can update information in your Jane account.
If you’re using one of our clearinghouse options that are in beta testing, please provide as much information as you can regarding your rejection.
Pro Tip:Some clearinghouses may flag your resubmission as a duplicate claim (if they have a feature designed to catch potential duplicates). If so, you may need to temporarily disable this feature in your clearinghouse before uploading your new EDI for resubmission.
Scenario 2: Receiving a Rejection From a Payer
If a payer has rejected a claim you’ve submitted through your clearinghouse, they usually provide some instructions on how to proceed on the remittance.
If the payer has advised you to make your corrections and to resubmit the date of service as a corrected claim, replacement of the prior claim, or as cancellation of the prior claim, then you’ll need to include a correction code and possibly a claim reference number (depending on the payer’s instructions) on your resubmission.
Let’s walk through an example together
Let’s say we’ve billed a date of service for a patient, and the payer rejects the claim because we forgot to include an initial treatment date, an authorization number, and we used an incompatible set of billing and diagnosis codes.
As with scenario 1, our first step would be to find the rejected claim in Jane, and mark it as unsubmitted. Likewise, we would then need to make our corrections in Jane. With this example, we would need to head to this patient’s profile and update their policy information (their ‘claim’), as well as the codes we’ve included on the date of service.
Once we have made our corrections (and updated our invoices if required), we can produce another EDI file for the date of service using our normal EDI generation work flow. Please feel free to have a look at our Generating an EDI File guide for more information on using Jane’s EDI feature to help manage your insurance submissions.
Before we generate our new EDI file for resubmission, we’ll see an option to add in a resubmission/corrected code as well as a claim reference number. This area maps to the equivalent of box 22 on a CMS-1500 form.
If we are unsure what code to use or if a reference number is required, we should be able to find that information on the payer rejection. We only need to resubmit with a correction code and reference number if advised by the payer.
Once we have selected our correction code and entered our reference number, we can generate a new EDI file for resubmission!
Pro Tip: You will only see an option to include a correction code and reference number if you have generated an EDI file for the date of service in the past.
If you have any questions along the way, please email us at firstname.lastname@example.org for some extra help.