Steps for Reversing or Replacing Claims (Voiding or Adjusting Claims)

Reversing versus Replacing a Claim  

You may reverse and replace any finalized paid claim or you may simply reverse the claim.  

• A Reverse transaction negates everything on the claim including, but not limited to, the charged amount, the payment, and the units or visits. This is commonly referred to as “voiding” the claim.
• During the Replace transaction, the claim data will be pre-populated. You will have the option of changing the data prior to resubmission. This is commonly referred to as “adjusting” the claim.

To either reverse or replace a claim, begin by logging into your Trading Partner Account and select the View and Submit Claims link under the Form Entry Heading to access the Claim Status page. 

 To Reverse a claim: 

1. Search for a claim by clicking the icon. Enter the dates of service and member information to find a specific claim or date range of claims for a member and then select a claim from the Claim Status page.
2. Select Reverse at the lower right corner of the Claim Status page.
3. The next screen will auto-populate an adjustment process. Select the option to Reverse this claim only, which is the box on the far right of the screen.
4. Select Continue and click OK when the verification question pops up. You will receive a message stating that the claim has been successfully reversed and it will display the claim number with an R1 extension.  

To Replace a claim: 

1. Search for a claim by clicking the icon and select a claim from the Claim Status page.
2. Select Reverse at the lower right corner of the Claim Status page.
3. The next screen will automatically default to an adjustment option. The radio button on the left will be filled in, the middle box will be checked, and the far-right box (straight reversal) will be blank. This populates the information to Reverse this claim and create a new claim. Preserve the existing data by keeping the default setting on Use the data from this claim as basis for the new claim. The new claim will have all applicable data copied over.
4. Select Continue and click OK when the verification question pops up. You will then get a message that the claim was successfully reversed and the R1 will populate the screen.
5. The next screen that pops up will allow you to edit the claim information at the line level and it will display the claim number with an R1 extension at the top of the screen. Make adjustments needed on the claim. Click Save and then Adjudicate to start processing the claim through the edits. If there are any errors, you will see them populated on the next screen. Once the claim is processed, the message will display the claim number with an A1 extension.