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Claim adjustments

You might need to adjust claims when there are entry errors, pricing adjustments, or for other reasons. Based on the claim status and the check status, different actions will need to be taken to adjust the claim.

Important! Please refer to your office manager and trading partner for additional adjustment guidelines. These are general processing guidelines only.
  1. Make sure you know why (the reason) an adjustment is needed.
    • Claim shouldn't have been entered
    • Payment error (underpaid or overpaid)
    • Claim wasn't paid, but requires some type of correction (e.g. wrong billing code, etc.)
  2. Determine the status of the claim and where the check is. Claim was:
    • Not released (IP, HA, HP)
    • Released, but not included in a check run (R)
    • Included in a check run, but wasn't printed (R)
    • Check was printed, but was damaged, error, etc.) (R)
    • Check printed and updated, but wasn't mailed or the check was returned (P)
    • Check was cashed (P)

  3. The adjustment to use depends on the reason, the claim and check status. Use the chart below for step-by-step instructions for some common adjustment scenarios.

    Note: These processes might differ from your defined processes and are for informational and guidance purposes only.

Claim adjustment scenarios

Claim and draft/check status

Adjustment Reason 1:

Claim shouldn't have been entered (entered under wrong membership number, etc.)

 Adjustment Reason 2:

Payment adjustment or non-payment issue requiring correction

(payment error, claim underpaid, overpaid, etc.)

non-payment error requiring correction (wrong service dates, etc.)
Claim Status IP—In process, HA—Held for audit, HP—Held for pend
Not yet released—no check Delete the claim, see Delete a claim

Correct the claim in claims processing, see Open and update a claim in processing
Claim Status R—Released

Not selected for a check run—no check

 Delete the claim, see Delete a released R claim

Reverse, reissue, and correct the claim, see Reverse a released claim with no check

  1. Reverse by reference number
  2. Reissue manually
  3. Correct the adjusted claim

Or

Recall a released claim

Selected for check run but no checks were printed
  1. Remove the claim from the check run
  2. Reverse or void by reference number
  3. Reissue manually
  4. Correct the adjusted claim

See Reverse a released claim with no check
Checks printed but aren't complete or okay
  • Complete the check run
  • Reverse or void by draft and check number
  • Reissue manually
  • Correct the adjusted claim

See Reverse a released claim with a printed uncashed check

Check run complete, check not mailed, or check mailed and returned

  • Reverse or void by draft and check number
  • Reissue manually
  • Correct the adjusted claim

See Reverse a released claim with a printed uncashed check
Claim Status P—Paid
Check Cashed

See Overpayment refund

See Overpayment refund

If the paid claims are associated with a disputed case and you have received money to be credited, see Adjust claims associated with a disputed case.

If you receive a refund for a claim that was originally processed by a different insurance carrier, see Overpayment refund for historical converted claims.
Check was not cashed. The claim and check were processed correctly, but the check was damaged or destroyed.
  • Reverse the claim
  • Reissue automatically

See Reverse a paid claim with an uncashed check

See Adjust claims associated with a disputed case for reissuing damaged checks and crediting money from disputed cases.

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