CurrentMolina HealthcarePolicy N/A

Corrected and Adjustment Claims Reimbursement

Governs Molina Healthcare's requirements and timelines for submitting corrected, adjustment, and voided claims and specifies billing formats and codes providers must use; affects Molina providers submitting CMS-1500 (837P) and UB-04/837I claims across listed states and product lines.

Policy Summary

PayerMolina Healthcare

PolicyCorrected and Adjustment Claims Reimbursement

Policy CodePolicy N/A

Change TypeTemplate, guidance and state-specific updates

Effective DateN/A

Next Review DateJun 4, 2025

Key ActionSubmit corrected claims using proper frequency/resubmission codes and include the original Molina claim number (ICN) in the designated field or REF=F8.

SourceLink

POLICY UPDATE CHANGES

Updated template and Texas Medicaid guidance.

Changed Coding Disclaimer font and removed references to Virginia; updated pages and PI font.

Added remittance advice information to Medicaid section for Arizona.

Added information regarding Texas Medicaid deadline for corrected claims.

Added information regarding Iowa Medicaid deadline for corrected claims.

xx7/xx8bill types used for adjustments (xx7) and voids (xx8)

FL64original Molina claim number placement (UB-04)

FL22original claim number placement (CMS-1500)

state-specific

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

timely filing windows

2020-11-20policy original creation

Corrected and Adjustment Claims — When a Submission Qualifies

Corrected/Adjustment Claims Criteria

Guidance for processing corrected claims and what qualifies as an adjustment/void:

Corrected claims must include appropriate coding and reference the original claim number (UB-04 FL64 / CMS-1500 FL22 or electronic equivalent such as 2300 REF=F8) and any missing documentation (e.g., EOB, consent/necessity, invoice, MSRP, medical records) required to process the correction.

Corrected claims may be submitted on paper (CMS-1500 or UB-04) free of handwritten or stamped content or electronically via EDI (837I/837P) with appropriate frequency/resubmission codes and identifiers.

Use bill type ending in '7' (xx7) to adjust a previously paid claim (reverse and replace). Use bill type ending in '8' (xx8) to cancel (void) an original paid claim entirely.

Adjustments and voids apply only to previously paid claims, including zero-paid claims; resubmitting a denied claim is not an adjustment and must be handled as a new claim submission.

When using 'xx7' to adjust a paid claim, do not change the pay-to provider number, Molina member consumer ID, or the original bill type on the paid claim.

Corrected claims submitted after federal, state, or company timely filing limits will be denied unless the provider can demonstrate the submission was made within the designated filing deadline (state-specific timeframes apply).

Claim Identifiers, Codes, and Where to Place Original Claim Numbers

Key 837/Claim Identifiersmixed

F8 (REF01)

Original Reference Number qualifier used in 2300 REF to convey Molina internal control number (ICN) for adjusted claims.

Frequency/Resubmission Codes

NUCC/UB guidanceFrequency/resubmission codes are defined in the NUCC manual (CMS‑1500) and the UB Editor (UB‑04); common values: 1=Original, 7=Replacement, 8=Void/Cancel Prior Claim.

Electronic 837 adjustmentsIn 5010X22x 837 adjustment transactions the CLM05‑3 (frequency code, last digit of bill type) must be set to '7' for replacements or '8' for voids (appears as 'xx7' or 'xx8').

Paper form placementWhen submitting paper claims, include the appropriate frequency/resubmission code in UB‑04 field 4 or CMS‑1500 field 22 as applicable.

Reference to original claimCorrected/adjustment submissions must reference the original claim number (ICN/Molina Claim Number) using 2300 REF=F8 (REF01=F8, REF02=ICN) for electronic adjustments and FL64 (UB‑04) or FL22 (CMS‑1500) on paper.

Meaning of 'xx7' and 'xx8'Use bill types ending in '7' (xx7) to indicate a replacement/corrected (adjustment) claim and bill types ending in '8' (xx8) to indicate a void/cancel of a prior paid claim.

How Providers Must Submit Corrected Claims

Billing Rule

Corrected claim submission: use proper frequency codes and reference original claim

Submit corrected claims as replacement or corrected claims using the proper frequency/resubmission codes and include the original Molina claim number. For paper claims, use UB-04 FL4 (Type of Bill) and FL64 (Document Control Number) or CMS-1500 FL22; for electronic 837 adjustments use CLM05-3 (bill type last digit xx7/xx8) and 2300 REF=F8 (REF01=F8, REF02=ICN) to convey the Molina internal control number.

Paper claims must be free of handwritten or stamped content and submitted on standard UB-04 or CMS-1500 forms.
Use frequency/resubmission codes per NUCC/UB manuals: 1=Original, 7=Replacement (xx7 for adjustments), 8=Void/Cancel (xx8 for voids).
Insert original claim number in UB-04 FL64 or CMS-1500 FL22 for paper; for 5010X22x 837 adjustments place original claim number in 2300 REF=F8 (REF01=F8, REF02=ICN).
Ensure corrected claims reference the original claim number and appropriate coding to indicate replacement or correction.

Form and Billing Type Definitions

CMS‑1500 (837P)

Form definitionCMS‑1500 (837P) is the standard form used to bill professional claims for physicians and non‑physician practitioners; it can also be used for drugs and durable medical equipment associated with a professional visit.

Typical usesUsed by physician offices and clinicians to submit professional services, outpatient facility physician services, and related supplies/drugs via paper CMS‑1500 or electronic 837P transactions.

Frequency code placementWhen submitting corrected CMS‑1500 paper claims, include the frequency/resubmission code in field 22 and record the original Molina claim number in field 22 as required.

UB‑04 (837I)

Form definitionUB‑04 (837I) is the standard form used to bill institutional claims for inpatient and outpatient services at hospitals, ambulatory surgery centers, dialysis centers, skilled nursing facilities and other institutional providers.

Policy Summary

PayerMolina Healthcare

PolicyCorrected and Adjustment Claims Reimbursement

Policy CodePolicy N/A

Change TypeTemplate, guidance and state-specific updates

Effective DateN/A

Next Review DateJun 4, 2025

Key ActionSubmit corrected claims using proper frequency/resubmission codes and include the original Molina claim number (ICN) in the designated field or REF=F8.

SourceLink

On This Page

Denial Risk

Timely filing deadline — late corrected claims risk denial

Corrected claims submitted after federal, state, or company timely filing limits will be denied unless the provider can document that the corrected claim was submitted within the designated filing deadline.

Services denied for failing to meet timely filing requirements are not eligible for reimbursement unless documentation proves timely submission.
State-specific timely filing windows apply (examples in policy include 30, 90, 365 days or other state product limits).

Used by hospitals and institutional providers to submit facility charges, revenue codes, and related services, including drugs and DME tied to the institutional visit.

Frequency code placementFor corrected UB‑04 paper claims, include the frequency/resubmission code in field 4 and insert the original Molina claim number in field 64 (FL64).

Type of Bill / Frequency Code

StructureType of Bill is a 3‑digit code that indicates facility type, type of care, and bill sequence (original/corrected/final).

Last digit meaningThe final digit of the 3‑digit bill type denotes original, replacement/corrected, or void/reversal status; use '7' to indicate replacement/adjustment and '8' to indicate void/cancel.

Electronic mappingIn 5010X22x 837 electronic transactions the CLM05‑3 field corresponds to the frequency code (last digit of Type of Bill) and will be set to '7' or '8' for replacements/voids (appearing as 'xx7' or 'xx8').

Explanation of Benefits (EOB)

DefinitionExplanation of Benefits (EOB) is a statement from the insurer that explains what services were billed, what the insurer paid, and what the patient may owe; it is not a bill but a summary of claim processing.

Role in corrected claimsAn EOB may be required when submitting corrected or replacement claims to document prior adjudication or to support the requested adjustment if listed as missing documentation.

Use with reference fieldsWhen filing electronic adjustments, include the original claim reference (2300 REF=F8 with REF02=ICN) so the EOB and insurer records can be tied to the corrected submission.