News: Corrected claims are accepted by Medicare

December 22, 2000

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Corrected claims are accepted by Medicare

By LINDA BASHAM
911 Billing Services and Consultant, Inc.

Medicare's Part B Bulletin dated July 2000, page 33 states:

In May, AdminaStar Federal adjusted a portion of the logic in the Medicare Part B claims processing system for both Indiana and Kentucky carriers. This change will allow claims with corrected diagnosis to be resubmitted as a new claim. The result is that claims will only deny as a duplicate where there is an exact match with a previously paid claim. If a claim is resubmitted with a corrected diagnosis and paid, the appeal for that claim in the pending inventory should be identified and dismissed.

This information can be found at the following web site http://www.astar-federal.com/anthem/affiliates/adminastar/medb/ky/index.html

Providers should be aware that when they receive denials from Medicare due to incomplete written insurance documentation they can resubmit the claim with a corrected diagnosis and/or narrative as a new claim.

Therefore, if a claim is denied and the submitter finds upon pulling back out the EMS form that there is additional documentation available that was overlooked on the original billing, that information can now be corrected and the claim can be refiled.

This would prevent the necessity to refile as a review or to overload the administrators with claims that they would struggle over and possibly still deny for lack of complete documentation.

Special attention should be paid on non-emergency runs to see if there is medical necessity and reasonableness for transporting the patient by ambulance. These should be plainly documented for the claims adjusters at Medicare. Simply stating that the patient is bed confined per HCFA guildelines or that you have a physician certification on file is not adequate for the adjucator to pay from. You must tell them why the patient is bed confined.

Rember: before you can bill most non emergency runs to Medicare you MUST have a Physician Certification Statement signed by the physician, RN, PA, or the Case manager involved in the patients care regardless of whether they feel it was necessary or not. You must have their signed certification in hand. Special rules on Physician Certification Statements can be found at http://www.hcfa.gov/pubforms/transmit/B000960.pdf.

As staff learn what Medicare adjusters are looking for and use those diagnosis codes, including those specific conditions in the narratives, you will find less denials to be a possiblity. We have been resubmitting claims under this bulletin policy with success.

Effective January 1, 2001 the Duplicate logic will be turned back on
for Medicare claims that have been denied for medical necessity. Once
again according to the December 2000 Part B Bulletin page 109 all
claims denied for any reason or paid will have to go thru the the
review process.

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