Resubmit claim
Send a corrected copy of the denied claim CL-20371.
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 4471 1501 6370. The last two digits were swapped.
Pick the new eligibility check. It is linked by its NPHIES response ID.
Claim after the change
- Patient
- Hessa Al Anazi
- Insurance Company
- Al Rajhi Takaful
- Claim type
- Vision
- Grand Total
- SAR 520.00
- Payer Share
- SAR 468.00
The full claim form opens with every section pre-filled from the original.