Correcting Claims in Availity/Aloha

Correcting Claims in Availity/Aloha

After you’ve processed claims through Aloha to get sent to Availity, you may encounter a situation where you need to fix or correct a claim. Before we get started, let’s define these words:  

Rejection: When a claim is rejected, the claim must be fixed so that it goes through to the payer. A rejected claim means that it got stuck in the clearinghouse (Availity) due to a clerical or demographic error, and has to be addressed before the payer receives it.
Denial: When a claim is denied, needs to be edited after submitting and has been received already, or voided, then it needs to be corrected. A denied claim has been received by the payer and denied for whatever reason, and needs to be addressed before resubmitting for reconsideration.
Claim rejections and denials can be handled in three ways:
  1. Release and Rebill in Aloha (Rejections)
  2. Directly through Availity (Denials)
  3. Claim Fix in Aloha (Denials)

Rejections (fix in Aloha):

Because the payer never received the claim to begin with and, you will release the claim out of Aloha, make your corrections, and rebill it as if it were a new claim. 

  1. Release the claim  

    1. Click the Billing icon > AR Manager > double click the payer name > select the claim > “More” in the top right corner > Release

  1. After releasing the claim, the claim will return back to the Billing Manager as if it were never billed in the first place.  

  1. Update the appointment by going back to the Schedule or Billing Manager to make your changes according to your rejection reason.  

  1. Return to the Billing Manager > Process Billing just as you did the first time

  1. Your claim has been sent off to Availity and reprocessed.  

Correcting a Claim (for Denials) through Aloha


If you choose to fix the claim in Aloha, it will automatically send it back to the clearinghouse.

  1. Claims need to be denied in AR Manager. Go to Billing > AR Manager > double click the payer name and select the corresponding claim that needs to be marked denied.  In the top right corner, click “More” and select “Denied”.  
    1. If you autoposted the ERA, it might have marked the claim as denied for you.
  2. In the pop up, enter the denial date, reason code, and any note you'd like to make about the denial. Click “apply” when done. 
  3. Denied claims will now appear under Billing > Fix Claim  
  4. Select the claim you want to correct and click “Fix Claim” in the top right.     
  5. Complete the necessary fields to update, just like how you would on the CMS1500 form.  
    1. In the Submission information window: 
      1. Resubmission code is equivalent to box 22 (7 for replacement of claim, 8 for voiding a claim)
      2. Original reference no (the claim number assigned by the payer) is equivalent to box 22  
      3. Additional claim information is equivalent to box 19  
    2. Update the changes you need to the claim itself for the denial reason (e.g. update units, auth number, etc.)  
  6. Click “Ready to Bill” when done.  
  7. On the left hand side in Billing, go to “Rebill” 
  8. Any claims that were ready to bill are now sitting in Rebill. Select the claim and process billing just like how you would in the Billing Manager.  
  9. Your claim has now been sent off to the clearing house and resubmitted.

Correcting a Claim (for Denials) through Availity

You can recreate a claim, and submit it as a replacement or cancellation (void) of the original claim, if the payer has already accepted the original claim for processing. Follow these steps:

1.  In the Availity Essentials navigation bar, select Claims & Payments > Claims & Encounters
2.  Begin filling in your organization information.  Click either Professional Claim, Facility Claim, or Dental Claim under Claims, depending on which type of claim you want to correct.  Typically behavior analytic claims are considered Professional Claims.  Then fill in the patient information.  
      

3.  Enter the claim information.  See HIPAA compliant sample below:


Set the billing frequency to either Replacement of Prior Claim or Void/Cancel of Prior Claim in the Claim Information section (for professional and facility claims).  You will use Replacement of Prior Claim if the claim has been processed and Void/Cancel of Prior Claim if the claim is still in processing.

Set the Payer Control Number (ICN / DCN) (or Payer Claim Control Number) field to the claim number assigned to the claim by the payer. You can obtain this number from the 835, if available.


4.  Submit the claim.

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