Use Special Submission Requirements. O = Original Original Initial submission of the claim No special requirements A = Amendment Correction To correct, update, add missing data elements values of a claim previously loaded in MH DW. Example: an incorrect data mapping to an Encounter field was remediated and impacted claim lines are now resubmitted to the MHDW with an “Amendment” Record Type and the correct value. Submitted with the Original Claim Number and Suffix Nothing should be entered in Former Claim / Suffix Number fields unless the amendment is for a previously adjusted claim, in which case the amendment record would inherit the former claim number/suffix from the claim it is amending. V = Void or Back Out Void To remove a claim line that was previously loaded in MH DW. Example: A paid claim was later denied. All previously submitted claim lines would be resubmitted with a “Void” Record Type. Submitted with new Claim Number/Suffix. Claim Number/Suffix of the claim to be voided must be placed in Former Claim Number/Suffix fields R = Replacement Adjustment To replace a claim that was previously loaded in the MH DW with one that has a new claim number. Example: the provider has resubmitted a claim under a new claim number. All previously submitted claim lines must be resubmitted with the new claim number and a “Replacement” Record Type. Submitted with new Claim Number/Suffix. Claim Number/Suffix of the claim that has to be replaced must be placed in Former Claim Number/Suffix fields. All claim lines need to be replaced with the new claim number. If there are more claim lines in the replacement claim than the original, submit the additional claim as an Original. Visa versa, if there are fewer claim lines in the replacement than the original, void the extra claim lines.
