CMS 1500 corrections

Submit the entire claim with corrections

Submit your entire corrected claim, not just the line items that were corrected, following the processes below, by U.S. Mail or electronically. Faxed or emailed claims will not be accepted.

Corrected claims will pend, not deny as duplicate or redundant, without your needing to call or email us.

Electronic CMS-1500 claim corrections

If you don't know where the 2300 loop or 2300 NTE ADD fields are in the form you use, contact your software vendor. If your software vendor has additional questions, contact our EDI team via email at edisetup@priorityhealth.com.

Enter Claim Frequency Type code (billing code) 7 for a replacement/correction, or 8 to void a prior claim, in the 2300 loop in the CLM*05 03.

To ensure we process the claim accurately, add a note explaining the reason for the resubmission in loop 2300 NTE (segment) ADD (Qualifier).

For example: NTE*ADD* (changed CPT)

Enter the original claim number in the 2300 loop in the REF*F8*.

Paper CMS-1500 claim corrections

In box 22a (Medicaid Resubmission), enter 7 (the "Replace" billing code). This will notify us that this is a corrected or replacement claim, and the claims examiners will not deny it as a duplicate claim. Use box 22 for this regardless of which Priority Health plan covers the patient.
In Box 22b (Original Ref. NO.), enter the original claims number. This will notify us of what claim is being corrected or replaced.
In box 19, add a note to indicate the reason for the resubmission. Examples: Changed CPT, added modifier, corrected EOB, etc.
If you are adding or changing clinical information on the claim, attach documentation.
Mail the corrected claim to the appropriate Priority Health claims processing address. You don't need to call or email us to alert us to your correction.

Adding a modifier

Submit medical records when appending a distinct service modifier (25, 59, or X [E, S, P, U]) to a line previously denied.

See code modifier billing guidelines for more details.

Checking claim status

Check the status of claims by using the Claims tool.

Billing codes for corrections

7 - Replace (replacement/correction of prior claim)
8 - Void (void/cancel of prior claim)

Clinical edit for adjusted claims

For accurate identification of facility claim corrections, facilities should report the appropriate adjustment indicator for a corrected or voided/canceled claim along with the claim change reason code. To accurately identify these, report with one of the following frequency codes:

Frequency code 7 should be reported to request an adjustment based on the corrected claim submission along with the appropriate claim change reason code (equal to condition codes D0-D4, D7, D8, D9*, or E0)
Frequency code 8 should be reported to request the claim be voided or cancelled along with the appropriate claim change reason code (equal to condition codes D5 and D6)

Claims reported without this frequency code and correct claim change reason code (see below) will be denied.

Claim change reason codes

D0 - Changes to service dates
D1 - Changes in charges
D2 - Changes in revenue code/HCPC
D3 - Second or subsequent interim PPS bill
D4 - Change in Grouper input (DRG)
D5 - Cancel only to correct a patient's Medicare ID number or provider number
D6 - Cancel only - duplicate payment, outpatient to inpatient overlap, OIG overpayment
D7 - Change to make Medicare secondary payer
D8 - Change to make Medicare primary payer
D9 - Any other changes (should be used only when no other change reason is applicable)

Use of condition code D9 should also include a remark to mirror bold criteria below on the second line of remarks:

Patient control nbr - changing or adding a patient control number
Admission hour - changing or adding the admission hour
Admission type - changing or adding the admission type
Admission source - changing or adding the admission source
Medical record number - changing or adding the medical record number
Condition code - changing or adding a condition code
Occ codes - changing or adding an occurrence code
Occ span codes - changing or adding an occurrence span code
Value codes - changing or adding a value code
Modifier - changing or adding a modifier
Date of service - changing a date of service on a line or changing the statement from and to dates, use a D0
Units - changing units
Recalculation - claim recalculated for a different payment
Multiple changes - enter your changes
DX code - changing a diagnosis code on an outpatient claim, inpatient claims would use a D4
POA - changing, adding, or removing a Present on Admission (POA) indicator, unless you are changing an N to a Y and/or if it affects reimbursement then you would use D4
Removed non - removing non-covered charges
Other - Place this information on the second line of the claim only. On the third line of claim include a brief description of why the claim is being adjusted

Submitting medical records

When you request an authorization, or a post payment appeal determination, you may need to send us medical records.

To submit medical records for a specific claim:

Log into your prism account
Click on Claims (medical)
Search for your claim. Make sure you're logged in as the group or facility the claim was paid under.
On the Claims Detail page, click Contact us About this Claim
In the dropdown menu, select Submit Medical Records
Attach medical records to your message

You’ll receive a confirmation screen after submitting your message, and a confirmation email from our Provider Services team.

To submit medical records for a Medicare claim for which you received a letter from us:

Log into your prism account
Click on General Requests
Click on New Request
In the dropdown menu, select Pended Claim requested medical records
Upload a copy of the letter we sent you requesting records

If you don't have a prism account, create one now.

Claim correction deadlines and timely filing

Follow-up is required within one year of the date of service, including resolving all claim and payment discrepancies. Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.

Providers have 90 days from date of the original denial (if close to or beyond one year from date of service) to resolve payment discrepancies including submitting corrected claims. This does not include upfront rejected claims or other insurance adjustment EOBs.

If you don't complete follow-up within 90 days, any request will deny without appeal rights.
Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.

Medicaid, Medicare and Commercial claims processing

Claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187.
We will notify you in writing of any problems or defects with your claim within 30 days; you will then have 30 days to correct and resubmit the claim.

90-day grace period

When Priority Health or another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Payment corrections from another health plan require the claim and EOB to be submitted to Priority Health.

Attach the EOB to the claim so we can verify the claim was submitted to us within the 90 days.
If you don't complete follow-up within 90 days, any request will deny without appeal rights.
Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.