Overview
In some cases, a claim should not stay on a member's record as an active claim. Examples are a claim created by mistake, a duplicate upload, or a member upload that should come from the provider instead. Depending on the situation, Yuzu can deny, void, or delete the claim. Each option affects what the member and provider see and what stays on record.
When a Claim Can Be Cancelled
A cancellation request is appropriate when:
Created in error: The claim was uploaded or entered by mistake, for example under the wrong member or for a service that did not occur.
Duplicate upload: The same claim was uploaded more than once.
Member upload that should come from the provider: The member uploaded a claim for a service the provider will bill directly. The provider's claim should be the claim of record.
If the claim is on the wrong member or coverage and the service is valid, request a move instead. See Fixing a Claim on the Wrong Member, Coverage, or Plan Year.
Understanding Denying, Voiding, and Deleting Claims
What happens | What the member and provider see | |
|---|---|---|
Deny | The claim stays on record and is adjudicated with no payment. A remark code explains the reason. | An EOB and EOP showing the denial and remark code. |
Void | The claim stays on record, but its billed amounts go to $0 and the claim is closed. A void entry is added to the claim history. | The claim shows $0 and no payment. Providers void their own claims by submitting frequency code 8. See Duplicate, Corrected, and Late Claims. |
Delete | The claim and its service lines, receipts, and details are permanently removed. This cannot be undone. | The claim no longer appears in the member or provider portal. |
Deletion should be limited to claims that were created in error and have not been paid. Claims that have been processed or paid are voided or denied so that a record of the payment remains.
Cancelling a Member-Uploaded Claim
If a member uploaded a claim that the provider will also bill, open a case to cancel the member upload. Do this before the provider submits, or as soon as possible after.
This prevents a duplicate denial. Yuzu's duplicate check compares new claims against approved claims. If the member upload was approved, the provider's claim may be denied as a duplicate. See Duplicate, Corrected, and Late Claims.
There is a consideration with this scenario:
Timely filing: Cancelling the member upload does not affect the provider's filing deadline. The limit is counted from when Yuzu first receives the provider's claim.
Requests to Delete Claim Information
Members may occasionally request that a claim or associated documents be removed from their records. Documents uploaded in error, such as an incorrect receipt or attachment, may be eligible for removal after review. However, claims that have already been processed or paid generally need to be retained for payment tracking, plan administration, and regulatory purposes.
How to Request a Claim Cancellation
If a claim needs to be cancelled, open a case directly on the affected claim.
Include the following:
Claim number: Identify the claim that needs to be cancelled.
Reason for cancellation: Explain whether the claim was created in error, is a duplicate, or should have been submitted by the provider.
Requestor: Indicate who the request came from.
Related claims: If the issue involves duplicate claims, identify which claim should remain active.
Yuzu will review the request and determine whether the claim should be denied, voided, deleted, or handled through another correction process.