Provider Quality

Fidelis Care would like to remind our provider community of the required protocols for submitting corrected claims and to clarify how these differ from appeals. Following these guidelines helps ensure timely and accurate claims processing.

What Is a Corrected Claim?

A corrected claim is used when the provider needs to modify or replace a previously submitted claim due to an error—such as coding, billing, or demographic inaccuracies.

Examples include:

• Incorrect procedure code
• Wrong units of service
• Member demographic correction
• Billing error requiring claim replacement

Corrected claims must follow the format requirements above and be submitted within 60 calendar days from the date of the remittance.

Submitting Corrected Claims

Electronic Submission of Corrected Claims

• The original claim number must be submitted
  • REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• 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
• For a corrected claim for a full retraction, the bill type must end in 8
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day

For UB‑04 Corrected Claims

• The Type of Bill (FL 04) must end in 7.
• The Document Control Number (FL 64) must include the Fidelis Care original claim number.
   

For CMS‑1500 Corrected Claims

• The Resubmission Code (FL 22) must be billed with a 7.
• The Original Reference Number field must include the Fidelis Care original claim number.
   

Important:

• Claims not billed according to these guidelines will not be accepted and will be returned to the provider.
• Corrected claims should not be submitted using the Provider Appeals Form or Provider Portal Claim Dispute.

What Is an Appeal?

An appeal is not used for correcting billing errors. Instead, an appeal is appropriate after a claim has been processed, a remittance advice has been issued, and the provider is requesting a review of the determination.

• All Administrative Reviews and Provider Appeals must be submitted using either the Provider Appeals Form or the Dispute Submission feature in the Provider Portal.
• An appeal should not be used for first‑time claims or corrected claims.
• Requests (including reconsiderations, corrected claims, and disputes) must be received within 60 calendar days from the date of the remittance.
   

Examples of when to submit an appeal:

• You disagree with a denial reason.
• You believe documentation supports a different outcome.
• You are requesting reconsideration of a processed claim.

For additional support, please contact your Fidelis Care Provider Engagement Account Manager.  To find your designated representative, visit: Contact Your Designated Provider Relations Specialist.