Can Claims Under Audit Be Reversed?

– the claim was too old to reprocess and is now stuck in your system as a reversed/unpaid claim! Without authorization or assistance from the insurance helpdesk, it can’t be re-billed. To avoid unnecessary stress, PAAS recommends leaving the identified billing errors as is, and discussing with your assigned PAAS analyst. Since each PBM has its own auditing processes and procedures, the steps to resolve a billing error vary.

You may be wondering, “Well, when is it okay to reverse a prescription if we’ve identified an error?” A prescription under audit should never be reversed, unless the PBM auditor has given explicit approval to do so. For claims not under audit, PAAS recommends sticking to a 30-day timeframe, as each PBM and/or Plan may have a unique billing window. If that claim is outside of 30 days, you’ll want to contact the insurance helpdesk and have them help you through the reversal and correction process.

Keep in mind that Prescription Validation Requests are an exception, as they often specifically indicate the allowance to reverse and correct a claim. You will want to be sure you are appropriately filling out the documentation provided by the PBM to indicate that the claim was reversed and rebilled.

PAAS Tips:

• If you find yourself with a reversed claim that is now stuck and unable to be rebilled, call the PBM helpdesk and ask if they can:
  • Open a billing window that would allow you to rebill, or
  • Help submit a paper claim via a Universal Claim Form (UCF)
• PBMs may have their own UCF, or alternatively these can be purchased from NCPDP’s vendor, CommuniForm LLC.