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:
• Health Insurance Claim Number (HICN), 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 status of claim prior to filing.
1. If you use direct data entry (DDE) pdf file, access the beneficiary’s HIC 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 status of claims via the Secure Provider Online Tool (SPOT).
3. Contact the interactive voice response (IVR) pdf file 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 the history of the beneficiary’s claims.
In addition, if your claim includes repeat services or supplies, append modifiers and/or condition codes, as applicable. For a complete list of coding resources, refer to the Medicare Billing: 837I and Form CMS-1450 Fact Sheet external pdf file
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 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 some 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 you must wait for the cancelled claim to finalize before the new claim is submitted.
• 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/finalized claim, no action is necessary.
