Bienvenidos, Corredores!

Fidelis Care would like to inform our providers of a new claim denial reason code that will be used when COB claim resubmission requirements are not met. 

EX CODE:  50M

Short Description:  Claim resubmission requirements not met

Long Description:  COB resubmission requirements not met - missing resubmission code and/or reconsideration form

The denial reason will occur when providers do not indicate the appropriate resubmission code or do not include the reconsideration form. This denial reason code is specific to COB claims that have been resubmitted to Fidelis Care.

In order to avoid this 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