Claim Resubmission Playbook¶

Overview¶

This playbook provides step-by-step guidance for correcting and resubmitting rejected claims. Following these procedures maximizes recovery rates and minimizes time-to-payment.

Resubmission Principles¶

Golden Rules¶

1. Analyze Before Acting - Understand the rejection reason
2. Correct Completely - Address all issues in one resubmission
3. Document Everything - Maintain audit trail
4. Meet Deadlines - Respect timely filing limits
5. Escalate Appropriately - Know when to appeal

Resubmission Workflow¶

graph TD
    A[Rejection Received] --> B[Classify Rejection]
    B --> C{Correctable?}
    C -->|Yes| D[Apply Corrections]
    C -->|No| E[Initiate Appeal]
    D --> F[Validate FHIR Bundle]
    F --> G[Add Attachments]
    G --> H[Submit via NPHIES]
    H --> I[Track Response]
    I --> J{Accepted?}
    J -->|Yes| K[Close Case]
    J -->|No| L[Escalate]

Step-by-Step Process¶

Step 1: Classify the Rejection¶

Actions: 1. Review rejection code and message 2. Identify rejection category (Admin/Clinical/Technical/Coding/Eligibility) 3. Determine root cause 4. Estimate resubmission success probability

ClaimLinc Assistance: - Automatic rejection classification - Historical success rate for similar rejections - Recommended correction path

Step 2: Gather Required Information¶

Administrative Rejections: - Correct patient demographics - Valid authorization numbers - Updated provider information

Clinical Rejections: - Clinical notes - Lab results - Imaging reports - Physician letters

Coding Rejections: - Correct diagnosis codes - Proper procedure codes - Appropriate modifiers

Technical Rejections: - Valid FHIR structure - Complete required fields - Proper formatting

Step 3: Apply Corrections¶

For Administrative Issues¶

Checklist:
[ ] Verify member ID against eligibility response
[ ] Confirm date of birth matches
[ ] Check provider NPI is active
[ ] Ensure authorization is valid and approved
[ ] Verify claim is not duplicate

For Clinical Issues¶

Checklist:
[ ] Obtain additional clinical documentation
[ ] Include physician attestation if needed
[ ] Attach relevant test results
[ ] Provide medical necessity justification
[ ] Reference clinical guidelines

For Coding Issues¶

Checklist:
[ ] Verify ICD-10 code accuracy
[ ] Check CPT/HCPCS validity for DOS
[ ] Review modifier requirements
[ ] Check for bundling/unbundling issues
[ ] Validate code combinations

Step 4: Validate FHIR Bundle¶

Pre-Submission Checks:

1. Schema Validation
2. All required fields present
3. Data types correct

4. References valid

5. Business Rules

6. Code system URLs valid
7. Values within allowed ranges

8. Logical consistency

9. NPHIES Requirements

10. Proper resource profiles
11. Correct identifiers
12. Valid attachments

Step 5: Prepare Attachments¶

Document Requirements:

Best Practices: - Clear, legible scans - Proper orientation - Relevant pages only - Secure file transfer

Step 6: Submit Resubmission¶

NPHIES Submission:

1. Generate corrected Claim resource
2. Include resubmission indicator
3. Reference original claim
4. Attach supporting documents
5. Submit via NPHIES API

Required Elements:

{
  "resourceType": "Claim",
  "status": "active",
  "related": [{
    "relationship": "prior",
    "reference": "Claim/original-claim-id"
  }],
  "billablePeriod": {...},
  "supportingInfo": [...]
}

Step 7: Track Response¶

Monitoring Actions: - Check NPHIES response within 24 hours - Log all status updates - Set escalation triggers - Prepare for additional requests

Response Types: - Accepted - Claim proceeding to adjudication - Rejected - Additional corrections needed - Pending - Under review

Payer-Specific Guidelines¶

Bupa Arabia¶

Key Requirements: - Complete clinical documentation - Valid prior authorization - Network provider verification

Tips: - Include care plan for chronic conditions - Attach discharge summary for inpatient - Provide itemized bills

Tawuniya¶

Key Requirements: - Accurate coding - Timely filing (180 days) - Package pricing compliance

Tips: - Use approved package codes - Include all diagnosis codes - Verify contracted rates

GlobeMed¶

Key Requirements: - TPA-specific documentation - Utilization review compliance - Pre-certification for elective

Tips: - Use GlobeMed forms - Include UR approval reference - Attach detailed reports

Appeal Process¶

When resubmission is not possible, initiate appeals:

Level 1: Informal Appeal¶

• Provider relations contact
• Phone or portal inquiry
• Documentation request

Level 2: Formal Appeal¶

• Written appeal letter
• Clinical rationale
• Supporting evidence

Level 3: External Review¶

• CCHI dispute resolution
• Independent review
• Regulatory intervention

Success Metrics¶

ClaimLinc Automation¶

BrainSAIT's ClaimLinc agent automates:

1. Rejection Analysis - Instant classification
2. Correction Suggestions - AI-powered recommendations
3. FHIR Validation - Pre-submission checks
4. Document Preparation - Attachment optimization
5. Submission Tracking - Real-time status

Related Documents¶

• Rejection Types
• Claim Lifecycle
• ClaimLinc Agent
• Automation Pipeline

Last updated: January 2025