ࡱ>  Lbjbj H22222$VVVPJVr,xNNNN~nL+++++++$l/2+i2N\\"NN+22NN,,"""NF2N2N+"N+"":a(,(N;lF( +B,0r,(R2&2(22(NN"NNNNN++!NNNr,NNNN2NNNNNNNNN : Corrected Claim Standard Cover Sheet GENERAL INSTRUCTIONS FOR PROVIDERS The Corrected Claim Standard Cover Sheet is completed when it is necessary to submit a corrected claim due to the correction of a diagnosis, date of service, charges, patient or provider information, procedure code, or a modifier addition or correction. To save an electronic copy of the completed form in your records: Completing the fields in the template form will not allow you to save it. Instead, before completing this form use the save as function, rename the document, and place the document in a folder or file on your computer. Locate the saved form in your folder or file, complete each field, save and print. The next time you access the template form on our Web site, a box with the question Do you want to open or save this file? will appear. By choosing save and following the same steps noted above, you can save an electronic copy of the completed form in your records.  Instructions for electronic submission: Please submit a corrected claim electronically using the HIPAA 837 standard claims transaction: Indicate the claim is a corrected claim by using the Claim Frequency Type Code data field. The value of this field must be 7. Indicate the reference number of the original claim using the Original Reference Number (ICN/DCN) data field when it is available. Instructions for paper submission: If you dont have electronic capability, follow these steps to complete and submit the Corrected Claims Standard Cover Sheet by U.S. Mail: Attach the updated claim form: CMS 1500 or UB-04 (formerly UB-92). Include the original claim number if available. The original claim number will be located on the Explanation of Payment (EOP). Complete each section of the Subscriber/Patient Information area. Complete each section of the Claim Identification Information. Mail the completed form with attachments to the address noted on the form below. This template may be updated periodically; dont print a large supply because it may become outdated. ( This is NOT a DUPLICATE claim. Please forward to the appropriate area for reprocessing. ( Subscriber Name: FORMTEXT      Subscriber Number: FORMTEXT      Patient Name: FORMTEXT      (MUST include plan prefix)Date Cover Sheet Prepared: FORMTEXT       Be sure to attach the updated claim form Claim Identification Information:Original Claim Number (from voucher): FORMTEXT      Provider Office Contact Person:Name: FORMTEXT      Phone Number: FORMTEXT      Other Information: FORMTEXT      This claim is a corrected billing of a previous processed claim for the following reason(s): FORMCHECKBOX  Corrected diagnosis FORMCHECKBOX  Corrected procedure code (CPT or CM) FORMCHECKBOX  Corrected date of service FORMCHECKBOX  Addition, or correction, of modifier FORMCHECKBOX  Corrected charges FORMCHECKBOX  Corrected provider information FORMCHECKBOX  Corrected patient information FORMCHECKBOX  Other: FORMTEXT      Any specific clarification/comment/instructions (e.g., the claim line that was corrected):  FORMTEXT       FORMTEXT       FORMTEXT      Supporting Documentation Attached? FORMCHECKBOX  Yes FORMCHECKBOX  No Please mail to Premera at the P.O. Box noted below: FORMCHECKBOX BlueCard Host or NASCO, P.O. Box 91059, Seattle WA 98111-9159 FORMCHECKBOX Dimensions (Heritage Plus, Heritage Select, and Global), P.O. Box 91059, Seattle WA 98111-9159 FORMCHECKBOX Federal Employee Program, P.O. 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They would like everything to go through the mail room (document control) to sort and scan the required forms. AH 12/27/2001 - Graphics (Sherron Olsen) and IT (Mike Gibson) were not able to locate the document. Needed to recreate the form without the HP logo. 12/28/2001- Deb Brady(OPs) verified that the correct address for Supplement to Medicare should be PO Box 91080, Seattle Wa 98111-9180. 01/02/2001 - *The Herd team asked that we make sure that when 18 mths has past we remove the PO Boxes for IMC and POS. *BlueCare & NASCO will have a new PO Box after the month of August. Only ordered enough to last until that month. 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