Claim Adjustment/Correction Process – Clarification

As Blue Cross Blue Shield of North Dakota (BCBSND) transitions to the new system, the method of adjusting/correcting claims will vary based on the member’s migration status as of the date of service on the original claim. “Claim Adjustment” is used to request an adjustment to a claim processed in the legacy system and “Claim Correction” is used to correct a claim processed in the new HMHS platform.

BCBSND is receiving a large volume of paper claim adjustments for members that have migrated to the new system. These claim adjustment requests will not be processed and you will need to follow the process outlined below for claim correction. If the claim you are trying to adjust is not found in THOR, it is likely a claim that processed on the HMHS platform (any claim that starts with ‘2’ is a claim from the new platform).

Adjustment/Correction will only be allowed for 180 days from the original claim processing date for both professional and institutional claims, regardless of which system the claim processed on.

Claim Correction

The Claim Correction process is used for claims processed on the new HMHS platform. As a reminder, claims for migrated members are processed on this platform. Details are outlined below for correcting professional and institutional claims in the new system, including specific information on out-of-state BCBS member claims. The below instructions are subject to change, so stay tuned for future Provider News emails on this topic.

Professional Claims

Claim/Billing Frequency Type codes are used when billing to indicate whether a claim is a new/original claim or a replacement of a previously adjudicated (approved or denied) claim.

Valid frequency types

There are three valid Billing Frequency Types:

  • Frequency Type 1 is an original claim. All new claims are submitted with this value.
  • Frequency Type 7 is a replacement of a prior claim. Frequency Type 7 is used to correct data reported incorrectly on the original claim. The original claim number assigned by BCBSND is required on this type of submission.
  • Frequency Type 8 is a void/cancellation of a prior claim. Frequency Type 8 is used to completely void a claim that was reported in error. The original claim number assigned by BCBSND is required on this type of submission.

Electronic 837P correction

The 837P allows you to submit a claim correction electronically using a valid Frequency Type code. Corrected claims can be submitted through the Professional or Facility Claim direct claim entry function in Availity Provider Portal by selecting the Billing Frequency Type 7 and providing the original claim number.

1500 paper claim correction

When submitting a claim correction request on a paper claim, enter a 7 for a corrected/replacement claim or an 8 to void a prior claim in Box 22 Resubmission Code, with the original BCBSND claim number entered in the Original Ref. No. field. Note: If the original claim was submitted on paper, the corrected replacement claim must also be submitted on paper.

Institutional Claims

To make changes to claims that have already been submitted through Availity, facility providers are to use correction Bill Types XX7 or XX8 for claims previously submitted by paper or electronically.

Correction bill types

Guidelines for correction Bill Types XX8 and XX7:

  • XX7 Replacement of prior claim: This code is to be used when a specific bill or line has been issued and needs to be restated in its entirety. When this code is used, BCBSND will operate on the principle that the original bill is null and void, and that the information present on this bill represents a complete replacement of the previously issued bill.
  • XX8 Void/Cancel Prior Claim: This code reflects the elimination in its entirety of a previously submitted bill. Use of XX8 will cause the bill to be completely canceled from the BCBSND system.
  • The original claim number is required when submitting correction bill types XX7 and XX8 on claims and 837I batch and real-time submissions. The original claim number should be reported in the Adjustment Claim Link (ACL) field.

Out-of-State BCBS Members and Fully Rejected Claims

When BCBSND providers see Blue Cross Blue Shield patients from other states (i.e. BCBSMN, Wellmark, Anthem), these claims are sent to BCBSND and for dates of service after 7/1/18, these claims are processed on the new HMHS platform. For these out-of-state member claims, the process for Claim Correction will follow the process outlined above except in the case of fully rejected claims.

Fully rejected claims may be related to benefits, reimbursement policy, non-covered services under the member’s plan, or services applied to member liability. Instead of submitting a claim correction in these situations, providers will be required to submit a brand-new claim (Frequency Type 1) that corrects the billing error(s) from the first claim. By submitting a new claim there will be no duplication concerns as the original claim was never identified in the system.

Please note, if there are some lines that paid, the claim would not be classified as fully rejected.

If providers try to submit a claim correction (rather than a new claim) for a fully rejected out-of-state BCBS member claim, they will receive the following on their remittance advice:

  • A claim adjustment group code of CO (contractual obligation),
  • A claim adjustment reason code of 16 (claim/service lacks information or has submission/billing errors), and
  • A remittance advice remark code of N152 (missing/incomplete/invalid replacement claim information)

Example: A claim for a BCBS of TX member is submitted through the new HMHS platform with the modifier 50 and only one unit assigned. The claim will not complete processing and will be rejected. The provider will receive notification of this rejection and should then submit a new claim with Frequency Type 1 with the modifier 50 and two units per the reimbursement policy for migrated membership.