Avoid Claim Denials for Ambetter

Date: 10/28/19

Ambetter from Superior HealthPlan providers can submit a corrected claim if a change or modification needs to be made to a claim that has already been submitted. The appropriate Centers for Medicare & Medicaid Services (CMS) billing form is required for claims submitted via paper or through Superior’s Secure Provider Portal and Electronic Data Interchange (EDI) claim submissions process.

In order to avoid delays in payment, denials or inaccurate processing, please note the following:

• Physicians and practitioners should utilize the CMS 1500 (02/12) Claim Form.
  • For CMS 1500 resubmissions: Box 22 must contain a resubmission code ‘7’ and reference the original claim number.
• Hospitals and facilities should utilize the CMS 1450 (UB-04) Claim Forms.
  • For paper UB 04 resubmissions: The Type of Bill (TOB) field must contain XX7 and reference original claim number in box 64.
  • For EDI UB 04 resubmissions: Field CLM05-3=7 and Ref*8 = Original Claim Number
• Submit paper corrected claims on standard red and white forms. Handwritten corrected claims will be rejected upfront.
• Follow instructions for submitting a correction for claims submitted on Superior’s Secure Provider Portal.

Providers should allow 30 days for electronic claims submissions or 45 days for paper claims submissions from the original/corrected submission date before submitting a correction. Submitting prematurely may cause inaccurate denials and recoupments.

For more information, please reference the 2019 Provider Billing & Manual. You can find the manual by visiting the Ambetter Provider Resources webpage, under the References section.