The Type of Bill (TOB) 117 is used by institutional providers (like hospitals) to submit a replacement or corrected claim for a previously adjudicated inpatient claim (Original TOB 111) that was submitted electronically via the EDI 837I format.
While the specific steps and required data elements can vary slightly by payer (e.g., Medicare, Medicaid, or private insurers), the general process involves the following critical steps:
1. Identify the Original Claim Details
- Locate the Remittance Advice (RA) or Electronic Remittance Advice (ERA): You need the payment details and the original claim reference number (also called Internal Control Number or ICN) assigned by the payer when the original claim was processed. This number is essential for linking the corrected claim to the original one.
- Determine the Error: Clearly identify what was incorrect on the original claim that requires the 117 replacement (e.g., wrong diagnosis/procedure code, incorrect charges, change in patient status, etc.).
2. Prepare the Corrected EDI 837I Claim
The replacement claim must be an entirely new EDI 837I submission that contains the corrected information.
- Change the Type of Bill (TOB):
- The fourth digit of the TOB is the frequency code. For a replacement or corrected claim, you must change the original TOB (e.g., 111 for the original claim) to 117.
- Include the Original Claim Reference Number: The original claim reference number must be entered in the appropriate loop and segment of the EDI 837I, which corresponds to Form Locator (FL) 64 on a paper UB-04 form. This is crucial for the payer to recognize the submission as a replacement.
- Enter the Corrected Data: All other fields on the claim must be completed, including the corrected information. The claim should reflect all services and charges for the period, not just the changes, as the replacement claim entirely voids and replaces the original.
- Add Condition Codes (If Applicable): Depending on the payer and the nature of the correction, specific condition codes may be required (e.g., on the UB-04, this would be FL 18-28) to explain the reason for the replacement.
- Note: For late-charge scenarios, some payers prefer a 117 to report charges not on the original bill, where the new claim includes both the original and additional charges.
3. Submission and Adjudication
- Submit the EDI 837I: Transmit the corrected claim electronically to the payer (or through your clearinghouse).
- Wait for a New Remittance Advice: The payer will adjudicate the 117 claim. The process generally voids the original claim and processes the new, corrected claim. Your next Remittance Advice will show the voiding of the old claim and the payment or denial for the new 117 claim.
Important Note: Adjustment and void claims are subject to the payer’s timely filing limits, which may differ from the initial claim filing limit. Always check the payer’s specific billing manual or companion guide for their most current rules.
Does the new claim sent with the 117 code use the original provider claim identification CLM01 as the original 111 sent?
o, the new claim sent with Type of Bill (TOB) 117 typically uses a new and unique CLM01 (Provider Claim Identification Number).
The CLM01 (Claim Segment 01), which corresponds to Form Locator 3 (Patient Control Number) on a paper UB-04 form, is used to identify the claim within the provider’s system. Payer systems often expect this to be a unique identifier for every transaction you send.
Here is a breakdown of how the identifiers are used:
Claim Identifiers on the EDI 837I
| Identifier | Segment/Element (EDI 837I) | UB-04 Field | Purpose on the 111 Claim | Purpose on the 117 Replacement Claim |
| Provider Claim ID | CLM01 | FL 3 | Unique internal number for the original claim. | New and Unique internal number for the replacement claim. |
| Original Payer Claim ID | REF (Loop 2300) with qualifier F8 (Original Reference Number) | FL 64 | Not used | Required. This is the Internal Control Number (ICN) assigned by the payer to the original 111 claim. |
| Type of Bill | HI Segment (Loop 2300) | FL 4 | 111 (Admission to Discharge) | 117 (Replacement of Prior Claim) |
Key Difference in the 117 Submission
- New CLM01: The replacement claim is a new submission, so it should have a new, unique identifier in the CLM01 to differentiate it in your own system and in the payer’s system, allowing for proper tracking and auditing.
- Original ICN is Required: To link the new 117 claim back to the payment history of the original 111 claim, you must include the Payer’s Internal Control Number (ICN)—the number they assigned when they processed the 111—in the designated loop (Loop 2300, REF segment with qualifier F8). This step is what tells the payer to void the original claim and replace it with the new 117 claim.
Always consult the payer’s specific EDI 837I Companion Guide for their precise requirements, as minor variations in field usage can exist between different payers (e.g., Medicare, Medicaid, or private insurance).
Please show references to the above explanation in the proper CMS procedures or other official manuals
That is a great request. When dealing with Medicare (CMS), the authoritative source for these billing rules is the Internet-Only Manual (IOM), specifically the Medicare Claims Processing Manual, Publication 100-04.
The principles outlined in the previous explanation regarding the Type of Bill (TOB) 117 and the required claim identifiers are directly supported by these official procedures and the corresponding EDI 837I Institutional Companion Guides published by the Medicare Administrative Contractors (MACs).
Here are the specific references:
1. Type of Bill (TOB) Structure and Code 117
The structure of the four-digit alphanumeric Type of Bill code and the meaning of the frequency code “7” are defined in the manual.
- Source: Medicare Claims Processing Manual (Pub 100-04), Chapter 3 – Inpatient Hospital Billing, or the general sections on Type of Bill Code Structure.
- Procedure: The fourth digit of the TOB is the “frequency” code.
- “1” (e.g., in TOB 111) is defined as an “Admit Through Discharge Claim” (the original claim).
- “7” (e.g., in TOB 117) is the code used for a “Replacement of Prior Claim” or “Adjustment Claim” when submitted by the provider. The term “replacement” is specific to the claim voiding the prior bill and resubmitting with corrections.
2. Provider Claim ID (CLM01) vs. Original ICN
The instruction to use a new Provider Claim Identification (CLM01) and include the payer’s Original Internal Control Number (ICN) is documented in the technical specifications for the EDI 837I transaction.
| Data Element | Requirement | Reference |
| Provider Claim ID (CLM01) | Must be unique. This field is the provider’s unique internal identifier for the current submission, which is the 117 claim. Medicare systems require unique identifiers for claim tracking. | EDI 837I Institutional Companion Guides (published by MACs), Loop 2300, CLM01 segment usage notes. |
| Original Payer Claim ID (ICN) | Required on the replacement claim (117). This is the ICN/reference number that Medicare assigned to the original paid/adjudicated 111 claim. This number is necessary for the system to identify, void, and replace the prior bill. | EDI 837I Institutional Companion Guides (published by MACs). This information is transmitted in the REF Segment with a qualifier (typically F8 for Original Reference Number) within Loop 2300 (Claim Information). |
In summary:
- 117 on the claim tells the payer what you are doing (replacing a prior bill).
- The F8/ICN in Loop 2300 tells the payer which original bill to void.
- The new CLM01 is simply the unique ID for the new electronic submission.
You should always refer to the specific Medicare Administrative Contractor (MAC) that processes your claims (e.g., Noridian, CGS, Palmetto GBA) and consult their latest EDI 837I Companion Guide for the most granular detail on segment and data element requirements.
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