The payer is telling you that they already have this claim in their adjudication system. To understand this, we will need to explain the difference between a denial and a rejection and the difference between resubmitting a claim and filing a corrected claim. We will then go in to some common reasons for this rejection.
Rejection versus a Denial
When a claim is submitted electronically to an insurance company, the claim first goes to their EDI Department. EDI stands for Electronic Data Interchange. The EDI department is going to perform some initial error checks. If they find errors, they will EDI Reject the claim. If they do not find any errors, they will then pass the claim to their adjudication department. The adjudication department determines if the claim should be paid based on the subscribers benefits and processes the claim.
When reading, notice we use the words "in general" as there are always exceptions to the general rule.
In general, an EDI rejection comes back to you in Therabill as a claim error. If the claim makes it in to the payers adjudication department, then information pertaining to the claim will come back by way of Explanation of Benefits or Electronic Remittance Advice (ERA).
In general, an EDI rejection (an electronic rejection that you receive in Therabill) has never made it to the adjudication department. Therefore, according to the adjudication department, it is like the claim never existed.
In general, a rejection can be resubmitted as a new claim while a denial needs to be submitted as a corrected claim.
I guess, the biggest difference is that a denied claim is considered to be adjudicated by the payer. A rejected claim is not considered to have been adjudicated by the payer. The next section of this article may shed a little more light on it.
Resubmission versus Corrected Claims
There are two fundamentally different methods for resending a claim. These two methods are resubmitting the claim and filing a corrected claim.
Resubmitting a claim
When you resubmit a claim, you are creating a new claim and sending it to the payer. The payer receives the claim and treats it as a new claim.
Filing a Corrected Claim
When you file a corrected claim, you are not creating a new submission. You are taking a claim that you previously sent and sending it to them again in such a way that the payer knows that this claim they are receiving has already been adjudicated by them and they should treat this new claim as a correction of a claim already in their adjudication department.
The problem arises when you resubmit a claim that was denied (as opposed to rejected). Because the original submission was denied, it is recorded at the insurance company as already having been adjudicated. When resubmitting, you are telling the insurance company "Here is a new claim". The insurance company receives it and says "this claim is a duplicate of a claim we have already adjudicated". This will result in a duplicate claim rejection (not denial) of your resubmission.
Common Reason for the Duplicate Claim Rejection and What You Should Do
- As described above, you may have resubmitted a claim that should have been filed as a corrected claim. If this is the case, then you should call the payer to find out how they want you to file a corrected claim. Therabill does have a tool that allows you to file corrected claims. Please see: Corrected Claims.
- You may have accidentally filed the claim twice. You can check your filing cabinet in Therabill to determine if you had already filed this claim before. You can also see this from the session history section on the edit session form. If you find that you did in fact accidentally file it twice, then simply click the Ignore Error button at the top of the claim error page in Therabill. If you do not think this is a duplicate claim, then you will need to call the payer to find out why they are telling you it is a duplicate.
- A fluke. When you send a claim to an insurance company, that claim may travel through multiple clearinghouses. It is not uncommon for the claim to be processed twice at one of the clearinghouses. It is also not uncommon for the insurance company to accidentally process the claim more than once. If this is the case, make sure you double check that you have been paid or have received some kind of response back from the payer on the claim. You may want to call the payer to make sure they are properly adjudicating your claim. If you find that they have paid you or that they are adjudicating your claim, you can click the Ignore Error button at the top of the claim error page.