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  • Connecticare Resubmission Request Form

Get Connecticare Resubmission Request Form

Reviously denied, but is within the 180 day filing limit, you may resubmit electronically. Otherwise, please submit with this form. Be sure to use a separate form for each request. Date Requested Claim # NDC# or formula HCPC, if applicable Date of Service Provider Name: Member Name Contact Name: Member ID # Contact Phone: Did you receive any payment for the claim noted above, including any amounts for which the member is responsible (i.e., deductible)? Please select the appropriate ".

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WHAT IS A CORRECTED CLAIM? A corrected claim is a replacement of a previously billed claim that requires a revision to coding, service dates, billed amounts or member information. CORRECTED CLAIM BILLING REQUIREMENTS.

Frequency code 7 Replacement of Prior Claim: Corrects a previously submitted claim. Frequency code 8 Void/Cancel of Prior Claim: Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims.

Professional Claims If you are submitting a void/replacement paper CMS 1500 claim, please complete box 22. For replacement or corrected claim enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.

▪ 1 – Original claim submission. ▪ 7 – replacement. ▪ 8 – void.

Frequency code (CLM05-03) The code 6 is labeled as corrected claim and the code 7 is labeled as replace submitted claim. It can be tough sometimes knowing what code a payer will want. If you need to file a corrected claim, it is best to first know what frequency code the payer accepts.

Frequency code 8: • Must be used to fully void a claim. Must represent the entire claim—not just the line or item that you are retracting.

If the claim was previously denied, but is within the 180 day filing limit, you may resubmit electronically.

Professional claims/CMS1500: Corrections should be billed using the claim number you are correcting and the proper resubmission codes, as outlined below: * -5 for late charges. * -7 for replacement of a prior claim. * -8 for voided or canceled claim.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232