RESUBMISSION
Resubmission refers to the process of re-submitting a claim to the insurance company or payer after it has been initially denied, rejected, or underpaid. This typically occurs when there are errors, missing information, or discrepancies in the original claim. Resubmission involves correcting the issues, providing additional documentation if necessary, and resending the claim for reconsideration and payment.
Why Claims Get Resubmitted:
- Missing information: This could be anything from patient demographic details to diagnosis codes or procedure codes.
- Incorrect coding: Using the wrong code for a service or diagnosis can lead to a denial. Example include
Incorrect Procedure Code: Let's say a doctor performed a minor skin biopsy, but the billing code used was for a more extensive surgical procedure. This would lead to a denial. You'd correct the code to the appropriate one for the minor biopsy and resubmit.
Missing Diagnosis Code: The claim might be missing a diagnosis code altogether, or the code might not match the service provided. You'd need to add the correct diagnosis code based on the doctor's notes and resubmit
- Lack of required documentation: The insurer might need additional medical records to approve the claim.
Example
Missing Referral: An insurance plan might require a referral for a specialist visit for coverage. If the referral wasn't submitted with the original claim, you'd need to obtain it from the referring doctor and resubmit with the claim.
Incomplete Progress Notes: The insurer might request the doctor's progress notes to understand the medical necessity of a service. You'd obtain the notes and attach them to the resubmission.
Resubmission Process:
- Identify the Error: You need to understand why the claim was denied in the first place. This information will usually be included in the Explanation of Benefits (EOB) you receive from the insurer.
- Correct the Errors: Make the necessary changes to the claim form and gather any missing documentation.
- Resubmit the Claim: You can typically resubmit electronically or by mail, depending on your insurance company's preference. Be sure to clearly mark the claim as a "resubmission" and include any relevant reference numbers.
Tips for Successful Resubmission:
- Act Quickly: The sooner you resubmit the claim, the sooner you can get paid.
- Be Accurate: Double-check all information on the resubmitted claim to avoid further delays.
- Attach Documentation: If additional information is needed, include it with the resubmission.
- Consider Reconsideration: If you believe the claim was incorrectly denied after resubmission, you might need to initiate a reconsideration process
