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Author's Note

When the term “claim adjustment(s)” is used in this article, it refers to electronic claim adjustment(s) unless otherwise stated. The terms Transaction(s) and File(s) are used interchangeably throughout this document.

I prefer to educate users rather than just provide instructions. However, I recognize there are times when you need to get things done—fast. If you're short on time and just need to know how to adjust a claim, you can skip ahead to the step-by-step instructions. Otherwise, keep reading to better understand the "why" behind it all.

Understanding the Challenge

ElderSuite is the most widely used software for Adult Day Care providers because we focus on enabling users to handle their administrative tasks entirely within the software—no third-party tools, no redundant entry, and no switching environments. That’s the goal.

However, when it comes to electronic claim adjustments, whether a payer accepts your adjusted claim is entirely up to their internal systems and policies. ElderSuite can prepare and submit the claim correctly using the proper EDI standards—but some payers simply don’t support them electronically.

A Brief Lesson on HIPAA and EDI Standards

The Health Insurance Portability and Accountability Act (HIPAA) includes provisions known as Administrative Simplification, which mandates the use of Electronic Data Interchange (EDI) for healthcare data.

In short:

• HIPAA requires that healthcare systems use a common communication standard (EDI).
• The version currently in use is ANSI ASC X12 Version 5010.
• Think of EDI as similar to HTML for the web—it’s what makes sure different systems can understand each other.

Without this standard, exchanging healthcare data would be chaotic.

Why Standards Matter

Standards are everywhere—from the bolts in your hardware to the code that powers the internet. The difference between EDI and something like HTML is simple:

• EDI is mandated by law.
• HTML is not.

This legal mandate helps ensure that when problems do arise with claim submissions, it's easy to trace whether the error lies with the sender or the receiver—because both are required to follow the same standard.

Common EDI Transaction Types

Here are a few transaction types you may encounter:

• 837P – Professional claims (used by ElderSuite)
• 837I – Institutional claims
• 835 – Remittance advice
• 276/277 – Claim status inquiries/responses
• 999 – File acknowledgment
• (and others: 270, 271, 278, 820, 834)

ElderSuite currently supports only the 837P format, as it's the only one required by our user base. If 837I becomes necessary, we’ll add it.

A Claim Is a Claim—Even When Adjusted

An adjusted claim is still just an 837P file. The only difference is the data inside—such as a corrected amount, procedure code, or diagnosis.

So why are some adjusted claims rejected?

Many payer systems identify adjusted claims as duplicates rather than replacements—especially if the same client and date of service are submitted again. Even if ElderSuite submits the claim properly, the payer’s system might not recognize it as a correction.

Example:

• Original claim: John Doe, 01/01/2019, $30.00.
• Adjustment: John Doe, 01/01/2019, ($30.00).

A system that doesn't recognize claim adjustments may reject the second claim as a duplicate, even though it contains corrected data.

In these cases, the payer may require you to submit the adjustment:

• Via their web portal, or
• Using a paper correction form.
  
  

Who Accepts Electronically Adjusted Claims?

TMHP (Texas Medicaid & Healthcare Partnership)

• Fully supports electronically adjusted claims.
• ElderSuite can successfully transmit them as long as you’re within the required adjustment timeframe.

MCOs / Star+Plus Contractors

• Inconsistent support.
• Many only accept adjustments via their web portals.
• A few may still require paper forms, and only a handful accept 837P adjustments directly.

Why the Inconsistency?

Many MCOs were late to adopt electronic adjustments. Initially, they required all corrections via paper (e.g., Form 1290). Some transitioned to online portals, but very few upgraded their systems to fully support 837P adjustments through third-party clearinghouses.

Because ElderSuite users span many payers across multiple regions, we cannot provide a definitive list of which payers accept electronically adjusted claims.

Why This Article Exists

We created this guide for two reasons:

1. Reduce repeat support questions – This gives users a single reference.
2. Clarify the nuances – To explain why a payer may reject your properly submitted adjustment.

Instructions: Adjusting Claims in ElderSuite

Important: ElderSuite supports electronic claim adjustments. However, successful acceptance depends on whether the payer’s system recognizes and processes adjusted 837P claims correctly.

How to Adjust a Claim in ElderSuite

Step 1: Sign In and Open the Claim Center

• Launch ElderSuite and log in.
• Click the Claim Center on the Navigation Bar.

Step 2: Scrub Claims

• Click Scrub Claims within the Claim Center.
• Enter the Start Date and End Date for the Date(s) of Service to locate the original claim.
• Click Find to retrieve matching claims.

Step 3: Open the Claim

• From the results list, locate the claim to adjust.
• Open it by:
  • Double-clicking the claim, or
  • Selecting it and clicking Edit Claim.

The claim will open on the HCFA 1500 form.

Step 4: Set Claim Status to Pending

• In the top-right corner of the form, change the Claim Status to Pending.
• This unlocks the form for editing and resubmission.

Step 5: Adjust Claim Data

• Update the Amount field, codes, or other data as needed.
• To indicate a refund or credit, use a minus sign (-). ElderSuite will format this automatically (e.g., ($30.00)).
• Make any other necessary corrections (e.g., diagnosis, service dates).

Step 6: Edit Resubmission Information (Item 22)

Locate Item 22 on the HCFA 1500 form to specify how the claim should be treated upon resubmission.

Resubmission Type Options:

• Original – Used for all new claims.
• Replacement – Used when correcting a previously submitted claim.
• Void – Cancels a previously submitted claim entirely.
• Reversal – Reverses a paid claim (if supported by payer).

ElderSuite automatically translates your selection into the correct resubmission code (e.g., 7 for Replacement, 8 for Void) in the 837P file.

Original Reference No.:

• Required for all resubmission types except Original.
• This is the claim number assigned by the payer (from the 835 or 277CA).
• If not entered when required, the payer may reject the claim or treat it as a duplicate.

Step 7: Save and Close

• Click Save & Close to save all changes to the claim.

Step 8: Submit the Adjusted Claim

• Back in the Claim Center, submit the adjusted claim just like any new claim.
• ElderSuite will generate a valid 837P file, including the updated amount and resubmission info.

Monitor the Outcome

After submitting the claim:

• Wait up to 24 hours for clearinghouse reports to appear.
• Download and review the:
  • Claim Status Report
  • Inquire Report

These reports will indicate if the claim was:

• Accepted by the payer
• Rejected due to formatting or data issues
• Denied as a duplicate or missing reference info

Summary of Key Resubmission Fields

Final Thoughts

Thanks for sticking with me. Whether you're processing one adjustment or a batch of them, I hope this guide helped you understand both the technical process and the reasons behind it.

Remember, ElderSuite will prepare and transmit the claim correctly—but the payer must also do their part for adjustments to go through.

When it works—it works great.
When it doesn’t—it’s usually the payer, not ElderSuite.