Claim Replacement 

Claims only need replacement if they have been accepted by the MCO. In this context, accepted is if the EDI 999 and EDI 277 are both Accepted.

If either the EDI 999 or EDI 277 are Rejected and the claim needs to be replaced, the claim can simply be resubmitted once the correct data is fixed. Having either an EDI 999 or EDI 277 Rejected is equivalent to the MCO never receiving the claim at all. Please see our FAQ on how to resubmit a rejected claim for more information.

You will need the reference number from the ERA. If Ambiki has received the ERA directly, the interface would provide this for you. If the ERA was mailed to you, you will need to provide the reference number.  

Ensure you are signed in to Ambiki and on the main dashboard

1. On the left navigation, click on ‘Patients’.

2. Select the patient for the claim replacement by clicking on their name.

3. Select ‘Payments’ at the top of the patient profile page.

4. Scroll down to the ‘Patient treatment reports’ section.

5. Click on the treatment report for the claim that needs to be corrected.

6. Click on ‘Invoice actions’ then ‘Correct claim’.
      a. ‘Correct claim’ will only be available if both the EDI 999 and EDI 277 have been ‘Accepted’.

7. Choose the correction type replacement.
      a. Replacement: The action of replacing a claim when there was a mistake in the original claim, but payment is still expected.

8. Add Claim note. 
      a. A detailed note must be added, explaining the reason for the claim replacement, like correcting treatment codes or provider details. This note is critical as it is reviewed by the insurance company.

9. Add the Reference number. 
      a. The claim’s reference number is crucial for the MCO to recognize the claim in relation to previous submissions.  You can use the reference number (reflected as 'payer claim control number') from the latest ERA (Electronic Remittance Advice), wait for a new ERA if the claim hasn't been processed yet, or manually enter a reference number obtained from external sources like Availity or MCO customer service.

10. Review and submit. 
      a. After completing the form, review the changes (highlighted in green for clarity) on a comparison page showcasing old and new claim data side by side. If the review is satisfactory, proceed by clicking the submission link to send the updated claim to the MCO.