General

1. Should I appeal my partially denied claim to add late charges?
2. We billed a claim and erroneously submitted some of the line items as non-covered. Do we need to appeal these charges since they are non-covered?
3. Should I request an appeal if my claim is paid but I forgot to add some charges when the claim was originally submitted?
4. When my claim finalized, one of the lines denied with reason code 5ARAN which states 'The information provided does not support the need for this service or item. See section 1862 (A)(1)(A) of the Social Security Act. These are non covered services because this is not deemed a "Medical Necessity" by the payer.' We realized that when the claim was billed, we didn't include one of the diagnosis codes that were in the medical records. Please advise what we need to do to receive payment on this claim.
5. How should we bill for a same day transfer?
6. Our SNF patient was sent to the hospital and was in observation for two days but was not admitted. Should I discharge my patient and then bill a separate claim?

1. Should I appeal my partially denied claim to add late charges?

   You would only need to request an appeal to add late charges if you are changing the denied line.  If you are adding late charges to a covered line, you would submit an adjustment claim making sure not to change anything on the denied line items.

   Date Posted: 04/25/2008

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2. We billed a claim and erroneously submitted some of the line items as non-covered. Do we need to appeal these charges since they are non-covered?

   No, if a provider submits a claim with non-covered line charges and the line level reason code is 31947, the original claim should be adjusted and the non-covered lines should be deleted using the 'd + home + enter' process.  Once the non-covered lines are deleted, they can be rekeyed as covered.  If you need additional assistance, please call the customer contact center for MD/DC providers at 1-866-488-0545 and for PA providers call 1-800-560-6170.

   Date Posted: 04/25/2008

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3. Should I request an appeal if my claim is paid but I forgot to add some charges when the claim was originally submitted?

   No, you should only request an appeal on a claim that is fully denied or partially denied.  If your claim was paid, you should submit an adjustment to add charges that were missed.  Please reference the Appeals Quick Reference Guide at http://www.highmarkmedicareservices.com/parta/selfservice/pdf/qr-med-a-appeals.pdf.  If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and MD/DC providers call 1-866-488-0545.

   Date Posted: 04/25/2008

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4. When my claim finalized, one of the lines denied with reason code 5ARAN which states 'The information provided does not support the need for this service or item. See section 1862 (A)(1)(A) of the Social Security Act. These are non covered services because this is not deemed a "Medical Necessity" by the payer.' We realized that when the claim was billed, we didn't include one of the diagnosis codes that were in the medical records. Please advise what we need to do to receive payment on this claim.

   You should submit a Clerical Error Reopening request.  The form and instructions are located at http://www.highmarkmedicareservices.com/parta/forms/medicare-reopening-request-form.pdf.

   Date Posted: 04/25/2008

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5. How should we bill for a same day transfer?

   A same day transfer is billed reporting '0' covered days, units and charges are billed as 'covered' and condition code '40'.  This information is located in the Centers for Medicare and Medicaid Service's Publication 100-4, Chapter 6, Section 40.3.3 at the following link:  http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf.  Also, for additional information, please reference the Quick Reference Guide for Filing a Medicare Part A claim at http://www.highmarkmedicareservices.com/parta/selfservice/pdf/how-to-file-a-medicare-clm(online).pdf.  For assistance, please call the customer contact center for PA providers at 1-800-560-6170 and MD/DC providers call 1-866-488-0545.

   Date Posted: 04/25/2008

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6. Our SNF patient was sent to the hospital and was in observation for two days but was not admitted. Should I discharge my patient and then bill a separate claim?

   The only time you would bill two separate claims is if the patient were actually admitted to the hospital as an inpatient.  If the patient is only in observation, you would bill a SNF leave of absence.  A leave of absence claim in this situation would be billed using one non-covered day, revenue code 180 with 1 unit and 0 charges.  You would also use occurrence span code 74 with the from and through date of the night the patient was not in your facility at the midnight census.  This information is in the CMS IOM Pub 100-04, Chapter 6, sections 40.3.4 and 40.3.5.2.

   Date Posted: 04/25/2008

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