The Fidelis Care Blog

Fidelis Care would like to inform our providers that a new claim denial reason code is in process for duplicate claim resubmission submitted on the same day.

EX CODE:  5V

Description:  Exceeded daily submission limit (or frequency) for this claim

Fidelis Care will process the first corrected claim received.  Any duplicate submissions of the claim on the same day will reject through the Electronic Data Interchange (EDI) system with the code ‘5V’.  This claim denial will not show on the remittance.

Providers will continue to see denial reason code ‘9L’ for invalid corrected claims.

In order to avoid denial, please follow the instructions below for claim corrections and reconsiderations:

Electronic Submission of Corrected COB Claims

• The original claim number must be submitted 
• The claim frequency type code must be a 7 (replacement of prior claim)
• 2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to a 7 and 2300 Loop
• REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day

Paper Submission of Corrected COB Claims:

• A fully completed Reconsideration/Appeal Request Form

• A valid Claim form (CMS-1500 or UB-04) containing resubmission code 7 and the previous claim #

COB Related Reconsiderations (the claim has previously been billed to Fidelis Care, and you are requesting a reconsideration or appeal)

• Accepted via paper submission only at this time. 
• Please include the following:
  • A fully completed Reconsideration/Appeal Request Form
  • A valid Claim form (CMS-1500 or UB-04)
  • An EOB from another insurance carrier/supporting documentation