Medical Claim Resubmission: When Should You Resubmit?

A medical claim did not process as expected. Should you correct it and send it again? Submit a replacement claim? Void the original claim? Or should you contact the health plan and request reconsideration or appeal?

The answer depends largely on what happened to the previous claim and whether the information submitted on that claim was correct.

One of the most important steps before resubmitting a medical claim is determining where the previous submission is in the claim lifecycle. A claim that encountered a rejection during claim submission or acceptance can require a very different response from a claim that has already been adjudicated, denied or paid.

This guide provides a general framework for reviewing medical claim resubmissions. Actual correction, resubmission, reconsideration and appeal requirements vary by health plan, payer, program and provider contract. Always follow the health plan's current instructions for the specific claim and situation.

Start With the Status of the Previous Claim

Do not decide how to resubmit a claim based only on the fact that payment has not been received.

First determine what happened to the previous submission.

The claim may have been:

• rejected during electronic claim submission or claim-acceptance edits
• accepted and still processing
• rejected during another stage of payer processing
• adjudicated and denied
• adjudicated and paid
• processed with incorrect claim information
• processed correctly but paid differently than expected
• identified as a duplicate
• waiting for additional information or another payer-specific action

Each of these situations can lead to a different next step.

Medical Claim Resubmission Decision Guide

The following table provides a general starting point for deciding what to review next.

This table is a decision guide rather than a universal set of payer rules. The health plan's instructions ultimately determine which submission or review process should be used.

Was the Claim Rejected During Submission or Before Adjudication?

A claim can be rejected at different stages of claim processing. For example, an electronic claim may fail front-end, formatting, implementation-guide or other claim-acceptance edits and be returned for correction before it proceeds further through the payer's processing workflow.

When a claim is rejected at one of these early stages, there may not yet be an adjudicated claim that needs to be replaced.

In many workflows, the provider corrects the reported rejection and resubmits the claim as an Original Claim using Claim Frequency Type Code 1.

However, the word rejected should not by itself be used to determine exactly how far a claim progressed. Payers and programs can use rejection terminology at different stages of processing. Review the actual acknowledgment, rejection report, claim status or payer response to determine where the claim failed and what action is required.

For a detailed explanation, see our Can You Resubmit a Rejected Medical Claim? guide.

Rejected Claim vs. Denied Claim

Before resubmitting, determine whether the claim encountered a rejection during submission or processing, or whether it reached adjudication and was denied.

For a closer look at this distinction, see our Rejected Medical Claim vs. Denied Medical Claim: What's the Difference? guide.

Was the Claim Already Adjudicated?

If the previous claim was already adjudicated, submitting another Original Claim may not be the appropriate way to make a correction.

Instead, determine whether the information on the previous claim was incorrect and whether the health plan requires a corrected or replacement claim.

For example, corrections might involve information such as:

• procedure or service information
• diagnosis information
• modifiers
• units
• dates of service
• charges
• provider information
• other information that was reported incorrectly or incompletely

The specific types of changes permitted through a corrected-claim process vary by health plan.

For additional guidance, see our Corrected Claim vs. Replacement Claim: What's the Difference? guide.

When Might You Need a Replacement Claim?

If an adjudicated claim contains information that needs to be corrected, the health plan may require a replacement claim.

For professional claims, Claim Frequency Type Code 7 is commonly used to identify a Replacement of Prior Claim.

The replacement submission will commonly require the payer-assigned identifier for the previous claim so the payer can identify which processed claim is being corrected or replaced.

For more information, see our Claim Frequency Type Code 7 - Replacement of Prior Claim Explained guide.

When Might You Need to Void a Claim?

Sometimes the previous claim should not be corrected and replaced. Instead, the provider may need to cancel the previously processed claim.

For professional claims, Claim Frequency Type Code 8 is commonly used to identify a Void/Cancel of Prior Claim.

A void may be considered when the entire prior claim was submitted in error and should be canceled rather than replaced with corrected information.

Voiding a previously paid claim can also result in payer-defined financial activity such as an adjustment, recovery or recoupment. Review the health plan's instructions before submitting the void.

For more information, see our Claim Frequency Type Code 8 - Void/Cancel of Prior Claim Explained guide.

Was the Claim Information Correct?

This may be the most important question when deciding whether another claim should be submitted.

If information on the claim was wrong, a corrected or replacement claim may be appropriate under the health plan's procedures.

But if the claim was submitted correctly and the provider instead disagrees with how the payer adjudicated it, changing and resubmitting the claim may not address the actual problem.

The appropriate next step could involve:

• claim review
• reconsideration
• provider dispute
• appeal
• another payer-specific review process

For a detailed discussion of this decision, see our Corrected Claim vs. Appeal: Which Should You Submit? guide.

What If the Claim Was Already Paid?

Payment does not necessarily prevent a claim from being corrected.

If an error is discovered after adjudication and payment, determine what information was incorrect and review the health plan's process for correcting the previously paid claim.

A correction can potentially change the payer's prior adjudication and may result in:

• additional payment
• reduced payment
• recoupment or recovery
• an overpayment
• an offset against another payment
• a payer-defined refund process
• an updated remittance or explanation of payment

Do not assume that submitting another Original Claim is the correct way to change a claim that has already been paid.

For more information, see our How to Correct a Medical Claim After It Has Been Paid guide.

What If You Need the Original Payer Claim Number?

Replacement and void workflows commonly require an identifier that allows the payer to associate the new submission with the previously processed claim.

Depending on the payer, this may be described as:

• Payer Claim Control Number
• Original Reference Number
• Original Claim Number
• Claim ID
• ICN
• DCN
• another payer-specific term

This is generally the payer-assigned identifier for the previous claim, not simply the provider's internal patient account number or claim number.

Before submitting a replacement or void, verify that you are using the identifier required by the health plan.

For a detailed explanation, see our Payer Claim Control Number & Original Reference Number Explained guide.

What If the Previous Claim Is Still Processing?

If the previous claim is still being processed, submitting another Original Claim may create a duplicate rather than speed up payment.

Instead, review the claim status through the available payer or clearinghouse workflow.

Depending on the payer, this might include:

• claim-status information in the payer portal
• clearinghouse claim history
• electronic claim-status transactions
• payer customer service or automated claim-status tools
• acknowledgment or claim-status reports

If the previous claim has already been received or adjudicated, determine what action is actually required before sending another submission.

What If the Claim Is Denied as a Duplicate?

If a payer identifies the claim as a duplicate, do not simply submit the same claim again.

First determine what prior claim or service the payer considers to be the duplicate.

The prior claim may already have been processed, the new claim may have been submitted while another claim was still processing, or legitimate repeated services may appear identical under the payer's duplicate-detection rules.

If the current submission was intended to correct a previously adjudicated claim, verify whether the payer expected a corrected or replacement claim instead of another Original Claim.

If the services were legitimately performed more than once, review whether the claim needs appropriate units, modifiers or other information required by the payer to distinguish the services.

For more information, see our Duplicate Medical Claim Denials: Causes and How to Avoid Them guide.

How Can the 277CA Help Before Resubmitting a Claim?

For electronic claims, the 277CA Health Care Claim Acknowledgment can provide useful information about whether a claim was accepted or rejected during claim-acceptance processing.

If a claim is rejected through this process, the 277CA may contain status information that helps identify the reported problem. That information can help the provider determine what needs to be corrected before the claim is submitted again.

However, acceptance on a 277CA does not mean that the claim has completed adjudication or will ultimately be paid. The claim may still proceed through additional payer edits, adjudication and payment processing.

A Simple Process Before Resubmitting Any Medical Claim

Common Medical Claim Resubmission Mistakes

Medical Claim Resubmission Examples

Example 1: Claim Rejected for Incorrect Subscriber Information

An electronic claim is rejected during claim-acceptance processing because required subscriber information is invalid.

Review: Correct the subscriber information and determine whether the payer requires the claim to be resubmitted as an Original Claim (1).

Example 2: Modifier Was Incorrect on an Adjudicated Claim

The payer has already adjudicated the claim, but the provider discovers that a modifier was reported incorrectly.

Review: Determine whether the health plan requires a corrected or Replacement Claim (7) referencing the previously processed claim.

Example 3: Claim Was Correct but the Provider Disagrees With the Denial

The submitted claim information accurately represented the services, but the provider believes the payer's denial was incorrect.

Review: Rather than changing correct claim information, determine whether the health plan requires reconsideration, claim review, dispute or appeal.

Example 4: Error Found After Payment

A claim has already been paid when the billing office discovers that information on the original submission was incorrect.

Review: Follow the health plan's process for correcting the previously paid claim and review how the correction may affect the original payment.

Example 5: No Payment Has Arrived

The provider has not received payment and is considering sending the claim again.

Review: Check the status of the original claim first. It may still be processing, may have been rejected or denied, or may require another action. Do not assume another Original Claim is necessary.

Example 6: Claim Denied as a Duplicate

The payer reports that the new submission duplicates another claim or service.

Review: Identify the prior claim or service causing the duplicate determination. Determine whether the current submission was unnecessary, was intended to be a replacement, or represents a legitimate separate service requiring another payer-defined action.

Frequently Asked Questions

Important: Claim submission, correction, replacement, void, reconsideration, dispute, appeal and timely filing requirements can vary by health plan, payer, government program and provider contract. This guide provides general information about common medical claim workflows and decision points. Always review and follow the health plan's current instructions for the specific claim and situation.

For technical requirements related to electronic professional claim submissions using the X12 837P transaction, refer to the official implementation guides published by X12 and the applicable payer companion guide.