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ICD-10 Claim Resubmission Guide & Appeal Letters

Claim errors are expected to arise as a result of the challenges in ICD-10 implementation. Your ICD-10 planning should include a review of your incorrect claim identification and resolution process. Make sure that once a claim is identified as incorrectly submitted, it is reworked promptly in order to comply with timely filing guidelines. Make sure that all billers understand that corrected claims must still be timely filed per the payer's filing requirements.

Also, stay on the look-out for any payer-specific ICD-10 claim filing guidance such as the following information from CMS Medicare Learning Network

ICD-10-CM/PCS Billing And Payment Frequently Asked Questions

Billers whose paper or electronic claims are returned or rejected for an invalid diagnosis code may correct or resubmit those claims. You will receive a letter of explanation or a Remittance Advice that provides information about claim errors. After the claim has been corrected, you must resubmit it as a new claim within the timely filing period. Claims that have been returned as unprocessable may not be appealed.

You may appeal initial claim determinations, including denials, if you are dissatisfied with the claim determination and file a timely appeal request that contains the necessary information needed to process the request.

If a denial is due to a minor error or omission you made in filing a claim, you may request a reopening to correct such clerical errors. A reopening is separate and distinct from the appeals process. After the claim has been corrected, you must resubmit it within the timely filing period.

As you assess your incorrect claim identification and resolution process, consider your organization's corrected claim follow-up process. Corrected claims should be reviewed within a short time to determine if the problematic claims were correctly processed as a result of the correction. If no processing has occurred, you may want to initiate a written inquiry via electronic inquiry or a more formal appeal, depending on both the payer and the expected outcome. To assist with this corrected claim follow-up process, review the following three letters for expediting corrected claim review:

Corrected Claim Submission Letter involving Payer-specific Requirements

Corrected Claim Submission Letter involving updated clinical documentation

Corrected Claim Submission Letter involving updated patient information

Sample ICD-10 Claim Resubmission Wording

Corrected Claim Due To Payer-specific ICD-10 Requirements

[~Current Date~]

Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Date: [~Treatment Date~]

Amount: [~Amount~]

Dear Claims Director,

According to our records, our office submitted an original claim on [~Insurance Policy #1 File Date~]. However, a corrected claim was filed due to notification of additional payer-specific ICD-10 requirements.

We do not show any decision related to the claim resubmission made on [corrected claim filing date].

Please review the attached information documenting the claim resubmission. Please provide a detailed explanation of why the corrected claim was pended/denied. Further, please furnish the name and coding credentials of the claims professional who reviewed the corrected claim, including the licensing organization and any recent ICD-10 coding training received by the reviewer.

Thank you for your assistance.

Closing Text,

Additional Customization Suggestions:

Attach Original Payer Denial/Correspondence

Attach Medical Records To Support ICD-10 Coding

Cite Published ICD-10 Coding information /Payer Guidance to Support Coding

Sample ICD-10 Claim Resubmission Follow-Up Letter

Corrected Claim Due To Updated Clinical Documentation

[~Current Date~]

Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Date: [~Treatment Date~]

Amount: [~Amount~]

Dear Claims Director,

According to our records, our office submitted an original claim on [~Insurance Policy #1 File Date~]. However, a corrected claim was filed due to updated clinical documentation.

We do not show any decision related to the claim resubmission made on [corrected claim filing date].

Please review the attached information documenting the claim resubmission. Please provide a detailed explanation of why the corrected claim was pended/denied. Further, please furnish the name and coding credentials of the claims professional who reviewed the corrected claim, including the licensing organization and any recent ICD-10 coding training received by the reviewer.

Thank you for your assistance.

Closing Text,

Additional Customization Suggestions:

Attach Original Payer Denial/Correspondence

Attach Medical Records To Support ICD-10 Coding

Cite Published ICD-10 Coding information /Payer Guidance to Support Coding

Sample ICD-10 Claim Resubmission Follow-Up Letter

Corrected Claim Due To Updated Patient Information

[~Current Date~]

Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Date: [~Treatment Date~]

Amount: [~Amount~]

Dear Claims Director,

According to our records, our office submitted an original claim on [~Insurance Policy #1 File Date~]. However, a corrected claim was filed due to receipt of additional patient information.

We do not show any decision related to the claim resubmission made on [corrected claim filing date].

Please review the attached information documenting the claim resubmission. Please provide a detailed explanation of why the corrected claim was pended/denied. Further, please furnish the name and coding credentials of the claims professional who reviewed the corrected claim, including the licensing organization and any recent ICD-10 coding training received by the reviewer.

Thank you for your assistance.

Closing Text,

Additional Customization Suggestions:

Attach Original Payer Denial/Correspondence

Attach Medical Records To Support ICD-10 Coding

Cite Published ICD-10 Coding information /Payer Guidance to Support Coding

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