Claim Resubmission
When a payer returns a claim - because it was rejected, sent back, or needs clarification or additional documents - you correct it and send it again. This is resubmission. This guide explains when a claim is eligible, the end-to-end flow, exactly which edits are permitted (and their limits), and how resubmission differs from recovering a claim that failed to transmit.
When a claim can be resubmitted
Two conditions must both hold:
- Provider-side state. The claim in your system must be in one of:
SUBMITTED,DRAFT_RESUBMIT,DRAFT_RESUBMIT_DOCUMENTS. - Payer-side (EDI) state. The claim's payer-side workflow state must be one of the states the payer
allows a claim to be pulled back from:
DRAFT_PROVIDER,CLOSED,CLARIFICATION_AFTER_AUTOMATIC_CHECKS,CLARIFICATION_AFTER_PAYER_CHECKS,CLARIFICATION_AFTER_PAYER_REVIEW,DRAFT_PROVIDER_RESUBMITTED,REJECTED,SENT_BACK,MISSING_DOCUMENTS,DRAFT_PROVIDER_RESUBMITTED_MISSING_DOCUMENTS,PROVIDER_RESUBMISSION_FINALISED.
If the payer-side state is not one of these, the claim cannot currently be resubmitted.
The resubmission flow
- Trigger resubmission. Call the resubmit endpoint for the claim. The HIE re-opens the authorization
on the payer side and moves the claim to
DRAFT_RESUBMIT- or toDRAFT_RESUBMIT_DOCUMENTSwhen the payer returned it asMISSING_DOCUMENTS. - Make your corrections. While the claim is in a
DRAFT_RESUBMIT*state you may edit it (see below). - Re-submit. Send the claim again through the normal submit route - Outpatient Claim Dispatch or Inpatient Claim Dispatch. Because the claim is in a resubmission state, the first-time-only fields (invoice number, discharge reason, consent) are not required again - they were captured on the original submission.
What you can edit on resubmission
While in DRAFT_RESUBMIT / DRAFT_RESUBMIT_DOCUMENTS, the permitted corrections are:
- Add attachments - typically to satisfy a
MISSING_DOCUMENTSreturn. See Adding Attachments. - Add diagnoses.
- Edit a claim line - adjust a line's unit price or quantity via Edit Claim Line.
Line amounts can only scale down
On resubmission a line amount may only be revised downwards. A PMF line's total cannot be edited to exceed its original (initial) line amount - the HIE rejects the edit if the new total is higher. Scale a line down to correct an over-bill; you cannot inflate a line during resubmission.
Resubmission is not the same as recovering a failed transmission
A claim in FAILED_TO_SUBMIT never reached the payer - it is a transmission problem, not a payer
return. You do not use the resubmit endpoint for it. Instead you re-call the normal submit route
(Submit outpatient / Discharge inpatient) directly, and the already-captured consent and discharge fields
are not re-required. See Preview Provider Claim for
how FAILED_TO_SUBMIT is detected and recovered.
Related resources
- Resubmit Claim
- Edit Claim Line
- Adding Attachments
- Preview Provider Claim
- Understanding Claim Statuses