Overview
Every claim processed by Yuzu is assigned to a specific member and their coverage. This determines which plan benefits apply, how much the member owes, how much the plan pays, and which deductible and out-of-pocket accumulators are updated.
Sometimes, a claim may be assigned to the wrong member or coverage. For example:
Wrong member: A claim for a dependent is incorrectly assigned to the subscriber
Wrong coverage: A member has multiple coverage records, and the claim is attached to the wrong one
Wrong plan year: A claim is processed under a previous or incorrect plan year, resulting in the wrong benefits or accumulators being applied
When this happens, the claim may be processed incorrectly, even if the information submitted by the provider was accurate.
Yuzu can generally correct these assignment errors by moving the claim to the appropriate coverage and reprocessing it.
Identifying the Source of the Error
The first step is to determine whether the issue originated with the provider or within Yuzu.
Provider submitted incorrect information: If the provider submitted incorrect information, such as the wrong member ID, name, or date of birth, the provider must submit a corrected claim. Yuzu cannot change the information originally billed by the provider. See Reprocess Requests.
Yuzu assigned the claim incorrectly: If the provider submitted the correct information but Yuzu matched the claim to the wrong member or coverage, Yuzu can correct the assignment and reprocess the claim.
Common Scenarios
Claim Assigned to the Wrong Member: A claim may be incorrectly matched to another member, particularly when family members share similar information. Yuzu can move the claim to the correct member's coverage and reprocess it. Any deductible or out-of-pocket amounts applied to the incorrect member will be reversed and applied to the correct member.
Claim Assigned to the Wrong Coverage: A member may have multiple coverage records, including annulled or historical coverage. Claims should be assigned to the coverage that was active on the date of service. If a claim was incorrectly assigned, Yuzu can move it to the appropriate coverage. Claims should not be moved onto annulled coverages. For more on how annulment affects claims, see Annulment vs. Termination.
Claim Assigned to the Wrong Plan Year: When a claim is assigned to the wrong plan year, it may be processed using incorrect benefits, deductible amounts, or out-of-pocket accumulators. Yuzu can move the claim to the correct plan year and reprocess it. Other claims may also require reprocessing if their cost shares are affected.
Claim Manually Uploaded to the Wrong Member: If a claim was manually uploaded to the wrong member account, do not upload it again, as this may create a duplicate. Instead, open a case on the original claim and request that it be moved to the correct member.
Limitations
Certain claims may require additional review before they can be moved:
Claims paid using a cash card
Claims where the correct plan does not have the same benefit tier
Processed or paid claims that need to be moved to coverage under a different employer group
In these situations, Yuzu will review the case and determine the appropriate next steps.
What Happens After the Claim Is Corrected?
Once the claim is moved and reprocessed:
EOB/EOP: Updated documents are issued reflecting the corrected claim.
Underpayments: If additional payment is owed, Yuzu sends the provider the difference.
Overpayments: If the provider was overpaid, Yuzu sends an Overpayment Notification letter and follows up every 45 days until repayment.
Accumulators: Deductible and out-of-pocket amounts are adjusted to reflect the correct member and coverage.
How to Request a Correction
Open a case directly on the affected claim and include:
Claim number
Correct member ID and coverage or plan year
Reason for the correction
Supporting documentation, such as eligibility dates or an ID card