Claim Correction Form

Resubmitted claims are prone to being rejected as duplicates.

Use this correction form, which can be filled out electronically and submitted as an e-mail attachment or printed and sent by mail or fax.

To complete the form, put the cursor in the first field, type into it, then tab to the next field. When completed, save the document as a separate file.

This form was developed in 2003 by the Plan-Provider Claims Workgroup, convened by HFMA, the American Association of Health Plans, and the National Coalition of Specialty Societies. The work group included representatives from the American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Academy of Dermatology Association, Orlando Regional Healthcare System, Bethesda Healthcare System, St. John Health System, Piedmont Hospital, Blue Cross Blue Shield of Florida, Group Health Incorporated, Health Alliance Plan, and Wellpoint Health Networks.