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.
Understanding the difference between rejections from a clearinghouse vs rejections from a payer is really important, as both cases are dealt with differently.
A rejection from a clearinghouse means the claim never actually made it to the insurer, so all you have to do is make a correction in Jane, and generate a new EDI file to submit. However, rejections from payers mean that the claim was received and processed by insurance. In these cases, you still have to make a correction in Jane and generate a new EDI file, but additionally, you often need to include more info in the new EDI file so the payer knows the claim you’re submitting is a corrected claim, rather than a new ‘original’ claim.
Below, we walk through how to manage rejections from your clearinghouse, and payer rejections in more detail:
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.
Alright, let’s dive into how you can complete all these steps!
Step 1: Correct the claim!
The first step is to correct your claim in Jane so it will be successfully processed when you resubmit it. The changes you have to make totally depend on the reason for the rejection. For example, you might have to edit the patient’s policy information by heading to Patient Billing > Insurance Policies, or you might need to adjust the billing codes on the patient’s visit.
Pro-tip: If the patient paid for a portion of the visit at the time of service (i.e. a copay) 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.
Step 2: Move the claim back to the Unsubmitted folder
Once the claim has been corrected, the next step is to actually resubmit it. You can only generate submissions for claims that are in the Unsubmitted or Draft states, so to start you’ll need to move the claim back to Unsubmitted.
There are a few different areas in Jane where you can manually mark a claim as unsubmitted. If you’re working in one of the Claim Submission folders, you can do so from the Claim Summary panel. It’s easiest to first View the submission, and then mark the claim as Unsubmitted from the Pre-flight Submission screen.
Step 3: Resubmit the claim to your clearinghouse (Clearinghouse Rejection)
Now that the claim is fixed and is back in the Unsubmitted folder, all that’s left to do is create a new electronic submission, and upload it to your clearinghouse.
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 rejects a claim you’ve submitted through your clearinghouse, then you’ll need to follow the exact same 3 steps that are outlined in Scenario 1. However, Step 3 looks a little different in this scenario. Those differences are outlined below:
Step 3: Resubmit the claim (Payer Rejection)
If the payer has rejected a claim you’ve submitted, then you’ll need to interpret the reason(s) they provided for the rejection (which is usually the trickiest part of the process!), and then resubmit the claim. Each insurance company has its own process and procedures for receiving resubmissions. Depending on the insurance company, you’ll need to mark your resubmission as a corrected claim, replacement of the prior claim, or as cancellation of the prior claim. Likewise, you’ll likely need to include the claim reference number from the original submission (which you should be able to find on the payer’s response), so the insurer can connect your resubmission with the original submission in their system.
When you go to create an additional submission under a claim, you’ll see a new area on the Claim Submission Pre-flight that enables you to select the type of resubmission/resubmission code (i.e. Corrected Claim), and enter the claim reference number.
Once you’ve entered that information, you’re ready to create your resubmission!
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.
If you have any questions along the way, please email us at [email protected] for some extra help.