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Corrected Claim Standard Cover Sheet Health Plan: Product: Attention: Date Cover Sheet Prepared: CORRECTED CLAIM MUST BE ATTACHED ? ? This is NOT a DUPLICATE claim. Please forward to the appropriate.

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Claim adjustments must include: TOB XX7. The Document Control Number (DCN) of the original claim. A claim change condition code and adjustment reason code. Optional: remarks to explain the reason for the adjustment. Remarks are required when the default condition code D9 and adjustment reason code OT are used.

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.

Complete box 22 (Resubmission Code) to include a 7 (the "Replace" billing code) to notify us of a corrected or replacement claim, or insert an 8 (the “Void” billing code) to let us know you are voiding a previously submitted claim.

UB-04 claim form This field is used to capture the original reference/claim number, which is required for corrected 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.

Corrected Claim Submission: EDI Claims Corrections can be sent in an electronic format. On the CMS-1500 Form, use Corrected Claim Indicator (Medicaid Resubmission Code). Enter the frequency code "7" in the "Code" field and the original claim number in the "Original Ref No." field.

UB-04: Corrections need to be submitted electronically with a type of bill of XX7 or on a paper UB-04 claim form with type of bill XX7 in box 4. All late charges for UB claims must be consolidated into one claim for submission. If the late charges are received separately, they will be denied as a billing error.

For CMS-1500 Claim Form - Stamp “Corrected Claim Billing” on the claim form - Use billing code “7” in box 22 (Resubmission Code field) - Payers original claim number should also be included in box 22 under the “Original Ref No.” field.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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:
+1 833 426 79 33
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