OBH Facets Duplicate Claim Handling

Original Effective Date: 12/28/2009

Revision Date: 09/04/2026
Main Menu
Overview Code Descriptions and Terminology
Purpose Code Descriptions
DUPS Warning Message Terminology
Procedures Revision History
Claim Cross Billing Business Details
Duplicate Exceptions
Duplicate Claim Review
Overview
Purpose This document provides essential guidelines for handling duplicate claims. Follow any plan specifics.
DUPS Warning Message

The warning message "DUPS – Possible Duplicate Claims On File for This Member" will appear on the following types of claims:

  • Related claims (ex. a profee claim and a hospital claim will come up as possible duplicates or claims for different Providers with the same TIN)
  • Similar claims (ex. claims with the same Provider/CPT/DOS but different charge amount, or claims in which some fields are off but almost all other information is the same)
  • Claims that are the same, but the original claim was denied (i.e., will show zero allowed).
Notes:
• If the claim is a Medicaid Reclamation claim. Follow the Medicaid Reclamation P&P first.
• If the claim is an ECT or Anesthesia claim. Follow the Facets ECT Treatment P&P.
Procedures
Claim Cross Billing
  • Refer to the Cross-Billing Prevailing Code List to determine the appropriate code to allow and code to deny. Cross-billing applies to services billed by the same Provider (example: Provider with the same name/TIN and credentials) for the same patient on the same date of service.
  • Note: This process does not apply to the following list of TINs that are excluded from the process.
    • Code to allow – Process per normal procedures.
    • Code to deny – Deny with the appropriate override Claim/Line Item Denial as follows:
      • If charges are billed by the same provider, select (W46/W47) for Services included in primary proc.
  • Virgin Island Providers excluded from cross-billing/duplicate claim.
Duplicate Exceptions Note: Refer to Duplicate Claim Exceptions below.
  • Providence business is excluded from the Physician Fee processing tips below if both of the below bullets apply:
    • Facility claim in history has a type of bill of 085 or 013 with revenue codes 510, 513, 521, or 900 and,
    • Professional claim has a 22 or 19 POS with the same DOS.
    Notes:
    • Follow the 0015 / DUP-POSSIBLE DUPLICATE CLAIMS ON FILE FOR THIS MEMBER section of Facets Warning Message Resolution document.
    • Do not deny claim as WCF if both of the above criteria are met for Providence. All other situations would apply to the step action documented below.
  • Exclude if the below bullets are met:
    • Facility claim has a revenue code of 510 and,
    • There is a professional claim billed with a POS 22 or 19 for the same DOS.
    Notes:
    • Follow the 0015 / DUP-POSSIBLE DUPLICATE CLAIMS ON FILE FOR THIS MEMBER instructions in the OBH Facets Warning Message Resolution instead.
    • Do not deny claim as WCF if both of the above criteria are met. All other situations would apply to the step action documented below.
  • Exclude if one of the facilities listed below bills with REV codes 0914, 0915, 0916, or 0513 and there is a professional claim with a POS of 22 or 19 on file for the same date of service. The following facilities are contracted effective 09/01/2019 to bill facility based services for both commercial and Medicare members. Notes:
    • Follow the 0015 / DUP-POSSIBLE DUPLICATE CLAIMS ON FILE FOR THIS MEMBER instructions in the Facets Warning Message Resolution document.
    • Do not deny claim as WCF if both of the above criteria are met. All other situations would apply to the step action documented below.
  • Monthly case services – Providers are allowed to bill more than one visit per day and multiple times in a month but will receive payment only one time for that month.
  • Per diem case services – Providers should only bill one service per day.
    • Providers may bill one service each day for every day of the month.
      • Allow one payment per day.
      • For per diem/day service duplicate charges – Let duplicate claim that is submitted for that day adjudicate with duplicate message.
  • 15 minute case services – Providers should bill each date of service on one line with the appropriate number of units on that line.
    • Allow payments on each line for the appropriate number of units billed.
    • If duplicate charge, let the duplicate claim submitted for same day and same number of units adjudicate with the duplicate message.
      • If there is a change in units billed or if no corrected claim, allow additional units and override the duplicate message (if it appears).
      • If there is a corrected claim, refer to Facets Claim Attachment Validation for instructions.
      • A claim from a different physician is not considered a duplicate claim.
Duplicate Claim Review
  • The steps below detail how the Claims Processor reviews the claim to determine if the claim is a true duplicate.
  • System is configured for frequency maximums. Examiners are not required to verify frequency in KL.
  • For Autism Claims proceed to the Facets Autism Claims policy.
Step Action
1

Was the claim submitted identified as a corrected claim or Void Claim?

Note: Review claim image for frequency 7 or 8.
Claim Image may reflect in the following sections:
• Physician electronic claim box 12A; Facility Electronic – Last digit on bill type would reflect 7 or 8.
• Physician Paper Claim could be written "Corrected/Replacement claim".
  • Yes – The claim is a corrected claim and not a duplicate. Refer to Facets Claim Attachment Validation.
  • No – Continue to next step.
2

Determine if the claim criteria listed below matches the current claim.

  • Claim Criteria:
    • Provider NPI or Provider Tax Identification Number (TIN).
    • Member.
    • Date of Service (DOS)
    • Procedure (excluding modifier(s))
  • All items match: Skip to Step 4.
  • Any item/items do not match: Proceed to the next step.
3
  • Refer to the Cross-Billing Prevailing Code List to determine the appropriate code to allow and code to deny. This list will also indicate the instances in which both codes are payable when billed with appropriate modifier types.

Exceptions:

If...Then...
If billing POS indicates inpatientMore than one profee code can be paid per day as not the same CPT code and do not follow Cross-Billing. Proceed to next step.
If the claim reflects add on codes.Do not follow Cross-Billing. Proceed to next step.
If the claim reflects an H, S, T (Code)Do not follow Cross-Billing. Proceed to next step.
  • Cross-billing applies to services billed by the same Provider (same NPI/TIN and credentials) for the same patient on the same date of service.
  • Medicaid Reclamation claims pay to a different TAX ID number. Confirm the claim for possible duplicate is not a Medicaid Reclamation claim by reviewing the claim history window. View the duplicate claim image for rendering provider's information, to determine if it is a duplicate.
  • Cross billing will not apply when the same code is billed twice — proceed to next step.
  • If billing POS benefit application indicates inpatient, do not follow cross-billing. More than one profee code can be paid per day as long as they are not the same CPT code.
If...And...Then...
If the codes are on the Cross-Billing prevailing codes list. Both claims are being billed by the same provider. Deny or Pay the code based on the Cross-Billing Prevailing Code List Grid.
• Code to allow – Process per normal guidelines.
• Code to deny – Deny with the appropriate override Claim/Line Item Denial code (W46/47) for Services included in primary proc.
Note: If the claim in history paid in error, pend the claim (F5) to ADJ with a note on which claim to pay or deny per cross billing grid.
Proceed to Step 9.
If no results are returned Bypass duplicate and allow both CPT codes. Skip to Step 6.
4

Determine the status of the claim in history.

  • 11, or 15 – Process both the current claim and the claim in history per this policy and continue to the next step.
  • 02 – Proceed to the next step.
5

Did the claim(s) in history pay (i.e., paid amount in Claims Inquiry is more than $0)?

  • Yes – Proceed to the next step.
  • No – The claim in history did not pay; Bypass Duplicate Edit with EX Code 020 and proceed to Step 9.
6

Is the claim a Medicaid Claim?

  • Yes – Skip to Step 8.
  • No – Continue to next step.
7

Follow the table below to find the current claim situation and then proceed to Step 9.

Notes:
• Check Claims Inquiry to see what is different on the claim.
• Verify additional or changed modifiers. Alert: All data must match on the claim/claim line to be considered a duplicate:
• Same provider name/TIN/NPI  • Same procedure code and modifiers (all must match)
• View the claim images to confirm: DOS, POS, Billed amount, Units, DX (All required claim data)
If...And...Then...
Claim or claim lines are denying as a duplicate (e.g. CDD) NA Allow system to deny duplicate claim with ultra-blue edit CDD – Definite Duplicate Claim. If the claim is not being denied by the system, override and Deny the claim as a Duplicate E51/F51.
Current claim/claim line is a duplicate (service code including modifiers), except for the Provider (Different Names or TINs).
Note: Refer to Alert above to confirm if claim/claim line is a Duplicate.		 Providers are affiliated (Different names but Same Tax ID). Deny the claim as a Duplicate.
• Line level override – Reduce the allowable to 0.00 with EX code 003 and EOB code (E51).
• Claim level override – Claim denial 346 and EOB code (F51).
Providers are not affiliated (Same name but Different Tax ID). The line(s)/claim is not a duplicate. Apply line/claim level override Bypass Duplicate Edit with EX code 020/o01.
Claim in history is a different TAX ID but it is a Medicaid Reclamation Claim. Deny the claim as a Duplicate.
• Line level override – Reduce the allowable to 0.00 with EX code 003 and EOB code (E51).
• Claim level override – Claim denial 346 and EOB code (F51).
Additional or changed billed amount/Allowed Amount. Deny the claim as a Duplicate.
• Line level override – Zero out the allowable and EOB code (E51).
• Claim level override – Claim denial 346 and EOB code (F51).
A different POS. Telehealth: If both claims are billed as Telehealth (POS 02/10) – Deny as a duplicate. Line level: Zero out allowable and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51).

Telehealth and any other POS: Provider are allowed to bill both Telehealth and other place of service in the same day. Bypass duplicate and allow payment.

Office Visit on both claims: Deny claim as duplicate.
Additional or changed units. Case Management Services: The line(s)/claim is not a duplicate. Apply line/claim level override Bypass Duplicate Edit with EX code 020/o01.

All Other Services: Deny the claim as a Duplicate. Line level: Zero out the allowable and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51).
The current claim has a newly added or changed Modifier. The line(s)/claim is not a duplicate. Apply line/claim level override Bypass Duplicate Edit with EX code 020/o01. Proceed to next step.
A corrected Explanation of Benefits (EOB). Add note, "Possible adjustment" with Details and Original claim number and pend (F5) the claim to ADJ.
Claim is a physician claim, and the Pro-fee has already been processed and paid under the Hospital Application. TINs match. Deny with EOB code (F24) for "Previously paid to same FED ID number".
TINs do not match. Deny with EOB code (E51/F51) for "Duplicate determined after review".
Claim is a professional claim with POS 22 or 19. There is a facility claim in history matching one of the facilities listed under the Duplicate Claim Exceptions portion of this P&P billing with the required type of bill and REV codes. Bypass possible duplicate and allow professional claim separately from facility/clinic fee.
Physician fee received on UB form; review Claim History to determine whether physician fees have already been submitted and paid to the physician. Physician fees have already been submitted and paid to the physician for the same procedure or HCPCS code on same date of service (DOS). Deny the facility Pro-fee with EOB code (F55) for "Chrgs are incl. to the pro component".
8

Follow the table below to find the current Medicaid claim situation:

Notes:
• Check Claims Inquiry to see what is different on the claim.
• Verify additional or changed modifiers.
If Current claim has...And...Then...
Claim or claim lines are denying as a duplicate (e.g. CDD) Allow system to deny duplicate claim with ultra-blue edit CDD – Definite Duplicate Claim. Proceed to next step.
Additional/changed billed or allowed amount. With no other changes to the claim. Deny the claim as a Duplicate. Line level: Reduce the allowable to 0.00 with EX code 003 and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51). Proceed to next step.
A corrected EOB attached. Add a note, "Possible adjustment" with Details and Original claim number and pend (F5) the claim to ADJ.
Provider billed claim with Telehealth place of service (02/10) or Modifier (95/GT). Telehealth: If both claims are billed as Telehealth (POS 02/10) with no other changes – Deny as a duplicate. Line level: Zero out the allowable and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51). Proceed to next step.

Office and Telehealth: Provider are allowed to bill both Telehealth and Office visit in the same day. Bypass duplicate and allow payment. Proceed to next step.
Current claim is a duplicate, except for the Provider (Different Names or TINs). Providers are affiliated (Different names but Same Tax ID). Deny the claim as a Duplicate. Line level: Reduce the allowable to 0.00 with EX code 003 and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51).
Providers are not affiliated (Same name but Different Tax ID). The line(s)/claim is not a duplicate. Apply line/claim level override Bypass Duplicate Edit with EX code 020/o01.
Claim in history is a different TAX ID but it is a Medicaid Reclamation Claim. Deny the claim as a Duplicate. Line level: Reduce the allowable to 0.00 with EX code 003 and EOB code (E51). Claim level: Claim denial 346 and EOB code (F51).
A different POS (excludes Telehealth POS); Additional or changed units; Same Procedure code with added or different modifier. The line(s)/claim is not a duplicate. Apply line/claim level override Bypass Duplicate Edit with EX code 020/o01. Proceed to next step.
9 (F3) Process the claim.
10 Resolve any additional warning and/or error messages.
11 (F4) Save the claim.
Code Descriptions and Terminology
Code Descriptions

Refer to the following documents for a full list of EOB codes and Medicare Reason codes used throughout this document:

  • EOB Codes List
  • Medicare Reason Codes
  • UM Service Group Code Glossary
Terminology See list of Terms, Abbreviations and Acronyms for a list of terms used throughout this document.
Revision History
Date Published Section Revision Details Writer Approver
09/12/25Duplicate Claim ReviewKMR 17629 – Updated Step 7 with an Alert and a Note to refer to the Alert.
09/08/25Duplicate Claim ReviewKMR 17577 – Updated Step 7 regarding service code including modifiers.
10/26/23Duplicate Claim ReviewKMR 3397 – Updates throughout the section.
10/06/23Duplicate Claim ReviewKMR 3289 – Updates throughout the section.
09/27/23Duplicate Claim ReviewKMR 3169 – Updated information about if the current claim is a duplicate, except for the Provider (Different Names or TINs) in Step 7 and 8.
06/16/23Overview; Duplicate Claim ReviewKMR 2046 – Added alert. Updated the steps Step/action table.
12/13/22Duplicate Claim ReviewWF-8923002 – Updated Step 8.
10/28/22Duplicate Claim ReviewAdded Step 1 and updated Denial codes.
09/12/22Duplicate Claim ReviewAdded alert in Overview and updated Step 2.
08/19/22Claim Cross BillingCM 24877 – Added additional language regarding cross-billing.
07/12/22AllWhole document updated.
03/10/22Duplicate Claim ReviewUpdated whole Step/Action table.
12/15/21Duplicate Claim ReviewUpdated Steps 4 and 5. Also, removed notes for Medicaid exclusions throughout.
11/12/21AllUpdated Title and overhauled the document.
10/25/21Overview, Duplicate Claim ExceptionsAdded note for exclusion of Medicaid plans.
12/29/20AllUpdated the whole document.
12/17/18Processing TipsAdded note.
11/06/18Processing Tips; Duplicate Claim ExceptionsConfiguration changes are being done via new contracts that are in place.
10/09/18Processing Tips; Duplicate Claim ExceptionsConfiguration changes are being done via new contracts that are in place.
10/03/18Processing TipsUpdated the link for Cross-Billing Prevailing Code List.
08/14/18AllAdded Providence business exceptions.
04/10/18AllConverted to HTML file format.
04/02/13AllInitial Release.
Business Details
Platforms Audience(s) State/DIV(s) LOB(s) Product(s) Documentation Contact
Facets Auditor
Processor
Adjuster		 All Commercial OBH Knowledge Management Request Form