<p> 1</p><p>Appeals/Reconsiderations</p><p>ISSUE:</p><p>Some reconsideration eBills are not identical to the original bill. Provider information is different or the attachment is different. Must the payer reject the reconsiderations unless they are identical to the original eBill?</p><p>RESOLUTION:</p><p> Reconsideration eBills MUST be IDENTICAL to the original eBill, with the exception of the added Condition Code and Original Reference Number, as described below. The reconsideration should contain an additional attachment with a letter explaining the reason why the reconsideration/appeal is being requested.  If the eBill has any changes in it, it should NOT be submitted as a reconsideration, but as a “corrected or replacement bill” by indicating the Claim Frequency Type Code in CLM05-3=”7” (Replacement). The Original eBill Identifier (ICN/DCN) must also be included in the corrected bill, so it can be related back to the original bill.  If the eBill is truly a reconsideration, then the CLM05-3 should be the same as the original denied eBill and the contents should be identical to the original. The Condition Code would contain the code indicating what type of reconsideration this is. The Condition Code is conveyed in the HI (institutional) K3 (Professional) or NTE (Dental) segment. The Original eBill Identifier (ICN/DCN) must be included in the reconsideration, so it can be related back to the original bill.</p><p>2</p><p>Corrected eBill </p><p> CLM05-3=7-required  Condition Code in HI/K3/NTE-W2,W3,W4 or W5 are not used  Original Reference Number in REF*F8-required </p><p>Reconsideration eBill</p><p> CLM05-3- required to be identical to the original  Condition Code in HI/K3/NTE-Required to have a CC of W2, W3, W4, OR W5  Original Reference Number in REF*F8-required</p><p>Note: In general, under Group Health, the corrected bills are submitted on paper rather than electronically because most adjudication systems see corrected bill as duplicate bills.</p>