Electronic Claim Adjustment Requests
Horizon recommends that claim adjustment requests be sent electronically via standard HIPAA 837 transaction sets. We accept electronic claim adjustment requests for professional (837P), institutional (837I) claims, and dental (837D).
Submitting claim adjustment requests electronically allows us to address your electronic adjustment requests more quickly, speeding our adjudication and payment to you.
You may electronically submit any adjustments that do NOT require the submission of additional supporting documentation, such as medical records, for:
- Local professional, institutional, and dental claims, including State Health Benefits Program.
- Federal Employee Program® (FEP®) professional, institutional, and dental claims.
- BlueCard® professional and institutional claims.
(Claims for your patients enrolled in other Blue Cross Blue Shield Plans that you submit to us for processing and reimbursement).
Contact your vendor or clearinghouse for information about 837 transactions. Most clearinghouses already send us 837 transactions and can work with you to submit adjustment requests in the appropriate format.
How to Indicate Your 837 Transaction Is an Adjustment Request
To indicate the electronic transaction you’re submitting is an adjustment request, include the following required information within your electronic 837 transaction:
The appropriate Frequency Code must be present on your 837 transaction to indicate the information being submitted is for a claim adjustment. The Frequency Code is reported in Loop 2300, Data Element CLM05:3 (“Claim Frequency Type Code”).
- Institutional claim adjustment submissions may use values 5, 7, 8, F, G, H, I, J, K, M, or N to indicate that the transaction is an adjustment.
- Professional and dental claim adjustment submissions may use values 7 or 8 to indicate that the transaction is an adjustment.
- Explanation for Adjustment
- Electronic Institutional claim adjustment requests must include in Loop 2300, Data Segment NTE (“Billing Note”) the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Subscriber ID corrections; Narrative: Transposed subscriber ID, correct Sub ID is 12345678 for John Smith, DOB 11-22-1970.)
- Electronic Professional and Dental claim adjustment requests must include in Loop 2300, Data Segment NTE (“Claim Note”) the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Number of units; Narrative: Units billed incorrectly, changed units from 010 to 001.)
Original Reference Number
All 837 electronic adjustment transactions must include the claim number of the originally processed claim found on your remittance advice (i.e., the ICN/DCN of the claim you want adjusted). This number should be listed in Loop 2300, Data Segment REF (“Payer Claim Control Number”) for all types of claims (Institutional, Professional, and Dental).
The Original Reference Number (ORN) submitted on the electronic adjustment can be found on the 835-remittance advice referenced by Claim Payment Information qualifier – CLP07 or the original claim number on your Explanation of Payment (EOP). The ORN is the only number that should be sent as the original adjudicated claim.
Original Claim Remittance Advice Resubmitted Claim Secondary Claim 2003 REF (F8) Not Used 2100 | CLP07 2300 | REF (F8) Not Used
Please share this information with your vendor or clearinghouse to ensure your electronic transactions are being submitted correctly.
BlueCard® and Federal Employee Program® (FEP®) are registered marks of the Blue Cross Blue Shield Association.