Adjustment Requests, Corrected/Replacement Claims, Attachments, and Coordination of Benefits (COB)

Important: Please use the following criteria to distinguish between an adjustment request, corrected claim (replacement of previously filed claim), or claim attachment. If you are resubmitting on a previously denied claim, you are not required to submit the claim as a replacement claim.

  1. Submitting a claim (original submission) with an attachment:
    1. If you are submitting an original claim, you must follow the instructions outlined below under Claim Attachment Instructions and include a Claim Attachment Cover Sheet.
  2. Submitting a corrected claim (rebill or replacement claim) with no special instructions:
    1. If you are submitting a corrected claim (rebill or replacement claim) where you have changed any information from the original claim and you do not need to communicate any special handling instructions for the resubmitted claim, follow the instructions under Corrected Claims.
  3. Submitting a corrected claim (rebill or replacement claim) with special handling instructions:
    1. If you need to communicate special handling instructions for the resubmitted claim, you must follow the instructions outlined in Claims Submission and include a Claim Attachment Cover Sheet. You will also need to complete and submit the Adjustment Request Form as the actual attachment with the Claim Attachment Cover Sheet if it helps explain the reason for resubmission and reduces the possibility of a denial of the resubmission. File the corrected claim electronically.
    2. Fax the Claim Attachment Cover Sheet and Adjustment Request Form along with supporting documentation to 1-320-762-1805.
  4. Submitting a replacement or voided claim:
    1. If you need to send in a replacement or voided claim for a previously paid claim, change the frequency type for 837P to a “7” to indicate a replacement claim or “8” to indicate a voided claim. For 837I, change the third digit of the bill type to a “7” to indicate a replacement claim or “8” to indicate a voided claim, following the Minnesota AUC best practice documents. Submitting a replacement or voided claim will require you to enter the last known paid claim number in loop 2300, REF, payer claim control number. Failure to do so will result in your claim being rejected.
    2. Replacement or voided claims should not be submitted until you have received the remittance advice from the claim you are replacing or voiding, or until the remittance is reviewable on the PrimeWest Health provider web portal. Failure to comply will result in your claim being rejected.
  5. Submitting a previously unauthorized services claim:
    1. If you are requesting an adjustment to a claim that was denied because the service was not authorized at the time and authorization has now been approved, resubmit the claim as an original claim with the authorization number on the claim
  6. Skilled Nursing Facility (SNF) claims:
    1. If you are requesting an adjustment to an SNF claim that was denied because the communication form was not included or updated and the communication form is now on file or updated, resubmit the claim as an original claim. 
  7. Submitting an adjustment request (no claim changes):
    1. If you are requesting an adjustment to a previously submitted claim that does not require a resubmission of the claim (there are no data changes to the claim) and the above scenarios do not apply, you must complete an Adjustment Request Form. The Adjustment Request Form must include the PrimeWest Health claim number and a description of the adjustment requested. The fax number for adjustment requests that do not accompany a claim submission is 1-320-762-1805.

Corrected/Replacement Claims

Submit a corrected claim when all or a portion of a claim is paid incorrectly (e.g., due to a billing error) or a third party payment is received after PrimeWest Health payment has been made. It is very important to include all lines on the claim, regardless of whether or not all lines paid incorrectly.

To qualify for a replacement, certain identifying information must remain the same. If these values change, the prior claim must be voided and a new claim must be sent with the appropriate frequency. If these items do not match the claim number referenced, your claim will be rejected. The following information must remain the same on the corrected/replacement claim:

  1. Provider (2010AA Loop)
  2. Patient (2010CA Loop)
  3. Payer (2010BB Loop)
  4. Subscriber (2010BA Loop)
  5. Institutional Statement Period (2300, DTP Segment)

Corrected or replacement claims must be submitted and received by PrimeWest Health within 180 days from the date of incorrect payment. Claims with dates of service 34 months old and older will be denied. You no longer need to complete an Adjustment Request Form unless you are requesting that PrimeWest Health recoup a previously submitted claim or need to communicate special handling instructions (see items 2 and 3 above). Submitting a replacement or voided claim will require you to enter the last known paid claim number in loop 2300, REF, payer claim control number. Failure to do so will result in your claim being rejected.

  1. Professional (837P), institutional (837I), and dental (837D) replacement claims must have the following fields completed:
    1. The claim frequency type code in CLM05-3 indicates the claim is an original, replacement, or a voided claim. For example, a value of “7” represents a replacement claim and value “8” represents a voided claim. The original PrimeWest Health claim number should be entered in Loop 2300, Segment REF, Payer Claim Control Number, when a claim is a replacement or void to a previously adjudicated claim.
    2. If using Office Ally (837P) enter the frequency type of “7” or “8” in Field 22 and the original PrimeWest Health claim number.

PW_03-19_115
Updated_12/06/2024