Last Modified: 10/21/2022
Location: FL, PR, USVI
Business: Part A
Q: My claim rejected, or was returned to provider, as a duplicate of another claim. Can I resubmit the claim? What steps can I take to avoid duplicate claims?
A: Claim system edits are in place to detect duplicate services. The edits search within paid, finalized, pending, and same claim details in history. This means that unless applicable modifiers and/or condition codes are included in your claim, the edits detect duplicate and repeat services within the same claim and/or based on a previously submitted claim.
The following reject reason codes are commonly seen with this edit:
• 38005 – This claim is a duplicate of a previously submitted inpatient claim
• 38031 – This outpatient claim is a possible duplicate to a previously submitted outpatient claim
• 38035 – This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider
• 38038 – This claim is a possible duplicate of a previously submitted claim
• 38200 – This is an exact duplicate of a previously submitted claim
The following return to provider (RTP) reason codes are commonly seen with this edit:
• 38032 – This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
• 38037 – This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
Your claim rejected as a duplicate, because one or more of the following items matched the original claim:
• Patient’s Medicare number, provider number, type of bill (TOB)–all three positions of any TOB, statement coverage from and through dates, at least one diagnosis or line item date of service, revenue code, HCPCS code, and/or total charges (0001 revenue line)
To prevent duplicate claims, verify claim status prior to filing.
1. If you use direct data entry (DDE)
, access the beneficiary's Medicare number to verify the history of claims submitted and the status/location of those claims. Note: you cannot see claims submitted by other facilities.
2. Check claim status via SPOT
3. Contact the interactive voice response (IVR)
system by calling (877) 602-8816. There are three breakdowns available: claim status, return to provider, and pending claims.
4. Review the remittance advice for a history of the beneficiary's claims.
If you submit claims via the electronic data interchange (EDI) gateway
, you are provided with confirmation when the batch of claims is received. Please wait for this confirmation, instead of resubmitting the batch of claims. If you make one change to one claim in the batch but resubmit the entire batch, all the claims go to the fiscal intermediary shared system (FISS), resulting in duplicate claims. Do not resubmit the entire batch; resubmit the corrected claims only.
Note: If a third-party vendor, billing service, or clearinghouse submits claims on your behalf, contact them to ensure they are not resubmitting entire batches of claims as described above. In addition, occasional software glitches can cause the resubmittal of an entire batch. Be aware that these software or vendor issues reflect directly upon the provider and are problematic, at best, and considered possible abuse, at worst.
Listed below are recommendations when additional action is required to correct your claim(s):
• You have two options when the original processed claim needs to be updated or corrected.
1. Adjust the original processed claim (TOB xx7) and resubmit.
2. Cancel the original processed claim (TOB xx8) and submit a new claim but wait for the cancelled claim to finalize before submitting the new claim.
• If two claims were submitted at the same time and resulted in duplicates against each other, submit a new claim.
• If the rejected claim is an exact duplicate to a previously processed and finalized claim, no action is necessary.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.