Resubmit claim
Send a corrected copy of the denied claim CL-20301.
Denied by the payer. Member is not covered on the service date. (BE-1-4). Fix the member details below, then send the claim again.
Original claim
The resubmission is sent against the original claim. The Related Claims panel cannot link a denied claim, so the link is kept here.
What you are changing
Was 4401 9331 5171. The last two digits were swapped.
Pick the new eligibility check. It is linked by its NPHIES response ID.
Claim after the change
- Patient
- Sara Al Qahtani
- Insurance Company
- Tawuniya
- Claim type
- Dental / Oral
- Grand Total
- SAR 410.00
- Payer Share
- SAR 369.00
The full claim form opens with every section pre-filled from the original.