Resubmit a Denied Claim

If a claim is denied or partially paid by a payer, a corrected claim would need to be sent for additional review. Submitting a corrected claim would require the claim frequency code '7', and the payer claim controlNumber must be included on the claim in the claimControlNumber field in the claimSupplementalInformation.

The claimControlNumber is the number assigned by the payer to identify a claim. Once submitted, the payer will review the claim and make any changes based on their internal review. The claimControlNumber is found on the payer 277 report.

The same process would need to be followed for voided claims, but using a frequency code '8'. Here is an example of a corrected claim:

{ "controlNumber": "000000001", "tradingPartnerServiceId": "9496", "submitter": { "organizationName": "REGIONAL PPO NETWORK", "contactInformation": { "name": "SUBMITTER CONTACT INFO", "phoneNumber": "123456789" } }, "receiver": { "organizationName": "EXTRA HEALTHY INSURANCE" }, "subscriber": { "memberId": "0000000001", "paymentResponsibilityLevelCode": "P", "firstName": "johnone", "lastName": "doeOne", "gender": "M", "dateOfBirth": "19800102", "policyNumber": "00001", "address": { "address1": "123 address1", "city": "city1", "state": "wa", "postalCode": "981010000" } }, "providers": [{ "providerType": "BillingProvider", "npi": "1760854442", "employerId": "123456789", "organizationName": "HAPPY DOCTORS GROUPPRACTICE", "address": { "address1": "000 address1", "city": "city2", "state": "tn", "postalCode": "372030000" }, "contactInformation": { "name": "janetwo doetwo", "phoneNumber": "0000000001" } }, { "providerType": "ReferringProvider", "npi": "1942788757", "firstName": "johntwo", "lastName": "doetwo", "employerId" : "123456" },{ "providerType": "RenderingProvider", "npi": "1942788757", "firstName": "janetwo", "lastName": "doetwo", "middleName": "middletwo", "ssn" : "000000000" }], "claimInformation": { "claimFilingCode": "CI", "patientControlNumber": "12345", "claimChargeAmount": "28.75", "placeOfServiceCode": "11", "claimFrequencyCode": "7", "signatureIndicator": "Y", "planParticipationCode": "A", "benefitsAssignmentCertificationIndicator": "Y", "releaseInformationCode": "Y", "claimSupplementalInformation": { "claimControlNumber": "12345" }, "healthCareCodeInformation": [{ "diagnosisTypeCode": "BK", "diagnosisCode": "496" },{ "diagnosisTypeCode": "BF", "diagnosisCode": "25000" }], "serviceFacilityLocation": { "organizationName": "HAPPY DOCTORS GROUP", "address": { "address1": "000 address1", "city": "city2", "state": "tn", "postalCode": "372030000" } }, "serviceLines":[ { "serviceDate": "20050514", "professionalService": { "procedureIdentifier": "HC", "lineItemChargeAmount": "25", "procedureCode": "E0570", "measurementUnit": "UN", "serviceUnitCount": "1", "compositeDiagnosisCodePointers": { "diagnosisCodePointers": ["1","2"] } } }, { "serviceDate": "20050514", "professionalService": { "procedureIdentifier": "HC", "lineItemChargeAmount": "3.75", "procedureCode": "A7003", "measurementUnit": "UN", "serviceUnitCount": "1", "compositeDiagnosisCodePointers": { "diagnosisCodePointers": ["1" ] } } } ] } }

{
  "controlNumber": "000000001",
  "tradingPartnerServiceId": "9496",
  "submitter": {
    "organizationName": "REGIONAL PPO NETWORK",
    "contactInformation": {
      "name": "SUBMITTER CONTACT INFO",
      "phoneNumber": "123456789"
    }
  },
  "receiver": {
    "organizationName": "EXTRA HEALTHY INSURANCE"
  },
  "subscriber": {
    "memberId": "0000000001",
    "paymentResponsibilityLevelCode": "P",
    "firstName": "johnone",
    "lastName": "doeOne",
    "gender": "M",
    "dateOfBirth": "19800102",
    "policyNumber": "00001",
    "address": {
      "address1": "123 address1",
      "city": "city1",
      "state": "wa",
      "postalCode": "981010000"
    }
  },
  "providers": [{
    "providerType": "BillingProvider",
    "npi": "1760854442",
    "employerId": "123456789",
    "organizationName": "HAPPY DOCTORS GROUPPRACTICE",
    "address": {
      "address1": "000 address1",
      "city": "city2",
      "state": "tn",
      "postalCode": "372030000"
    },
    "contactInformation": {
      "name": "janetwo doetwo",
      "phoneNumber": "0000000001"
    }
  },
  {
    "providerType": "ReferringProvider",
    "npi": "1942788757",
    "firstName": "johntwo",
    "lastName": "doetwo",
    "employerId" : "123456"
  },{
    "providerType": "RenderingProvider",
    "npi": "1942788757",
    "firstName": "janetwo",
    "lastName": "doetwo",
    "middleName": "middletwo",
    "ssn" : "000000000"
  }],
  "claimInformation": {
    "claimFilingCode": "CI",
    "patientControlNumber": "12345",
    "claimChargeAmount": "28.75",
    "placeOfServiceCode": "11",
    "claimFrequencyCode": "7",
    "signatureIndicator": "Y",
    "planParticipationCode": "A",
    "benefitsAssignmentCertificationIndicator": "Y",
    "releaseInformationCode": "Y",
    "claimSupplementalInformation": {
      "claimControlNumber": "12345"
    },
    "healthCareCodeInformation": [{
      "diagnosisTypeCode": "BK",
      "diagnosisCode": "496"
    },{
      "diagnosisTypeCode": "BF",
      "diagnosisCode": "25000"
    }],
    "serviceFacilityLocation": {
      "organizationName": "HAPPY DOCTORS GROUP",
      "address": {
        "address1": "000 address1",
        "city": "city2",
        "state": "tn",
        "postalCode": "372030000"
      }
      },
    "serviceLines":[ {
      "serviceDate": "20050514",
      "professionalService": {
        "procedureIdentifier": "HC",
        "lineItemChargeAmount": "25",
        "procedureCode": "E0570",
        "measurementUnit": "UN",
        "serviceUnitCount": "1",
        "compositeDiagnosisCodePointers": {
          "diagnosisCodePointers": ["1","2"]
        }
      }
      },
      {
        "serviceDate": "20050514",
        "professionalService": {
          "procedureIdentifier": "HC",
          "lineItemChargeAmount": "3.75",
          "procedureCode": "A7003",
          "measurementUnit": "UN",
          "serviceUnitCount": "1",
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": ["1" ]
          }
        }
        }
    ]
  }
}

ServiceLineReferenceInformation:
      type: object
      properties:
        repricedLineItemReferenceNumber:
          type: string
          description: 'Loop: 2400, Segment: REF, Element: REF02 Notes: When REF01=9B'
        adjustedRepricedLineItemReferenceNumber:
          type: string
          description: 'Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=9D'
        priorAuthorization:
          maxItems: 5
          minItems: 0
          type: array
          description: Loop 2400 REF
          items:

To include additional documents, use the Attachment Submission API. See also Attachment Submission API FAQ.