Replacement Vs Resubmission

Resubmission: A resubmission is required when the claim has been rejected. The claim has either been rejected by the clearinghouse or by the payer. Clearinghouse Rejection, means the claim never made it to the payer. The clearinghouse found an error on the claim before transferring it to the payer. Payer Rejection, means the payer found an error and rejected before it was entered into their system for adjudication. They did not process the claim and therefore the claim can be resubmitted.

Replacement: A replacement claim is required when the claim has reached the payer and has processed but denied for an error. You will receive an EOB explaining the reason for the denial. At this point, you would need to correct the error on the claim and request a replacement claim to the service center. They require a resubmission code to be listed on the claim along with original claim number. The resubmission code notifies that insurance this claim will replacing the original and to process it for payment. Medicare does not accept replacement claims, but commercial insurances do.