When initial claims to payors are denied, billers may either appeal the claim or submit a corrected claim in order to seek reimbursement for the services rendered. In order to ensure that providers receive reimbursement, billers must be aware of the differences between appealed and corrected claims and follow state and payor guidelines for submitting both.
Ms. Waibel and Ms. Spinner address three questions regarding appealed and corrected claims.
Q: What is the biggest mistake billers make when processing appealed and corrected claims?
A: Sending a claim through the appeals processes when it could have been sent as a corrected claim is common. Also, when submitting appeals, billers must include enough documentation to support the reason for the appeal. Often, billers do not include enough documentation in these claims.
Q: What is the difference of an appealed vs. a corrected claim?
A: When appealing a claim, you are advising the carrier that the codes billed are correct, and you are providing documentation showing that the codes are reimbursable as billed. When filing a corrected claim, you are advising the carrier that you would like to amend the CPT, ICD-9 and HCPCS codes originally billed. Knowing the difference and using the correct claim form are important so that the claim is reprocessed correctly and in a timely manner.
Q: What steps should billers take when processing appealed vs. corrected claims to ensure they are correctly submitted?
A: For a corrected claim, the appropriate changes should be made to the CPT, ICD-9 or HCPCS codes, and the bill type should be changed to reflect a corrected claim. Claim form 837 is typically used for corrected claims. If the bill type is not changed, it could be denied as a duplicate bill. The corrected claim should then be submitted electronically to ensure the quickest processing.
For an appealed claim, you must supply documentation to support your appeal. Make sure to include the operative note, any relevant CCI edits, the invoice, your official letter of appeal and a copy of the original claim. There are state-specific guidelines that can be used as well as payor-specific appeal processes.
Ref: Becker's Healthcare
This post was first published November 11, 2009 and was updated July 29, 2022.