Late Charge Claim Adjustments and Correction

Section: Coding Billing

Effective Date: January 01, 2024

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBND) policy for claim adjustments and corrections. This document provides directions for the proper billing for late charges billed by the same performing provider when a previous claim with the same date of service and/or date span has already been submitted.

Term

Definition

Late Charges

An additional service(s) and/or charges that were not initially included on the original claim

Policy

Providers must submit claim correction(s) when identified late charge(s) overlap a previously submitted claim’s date(s) of service (DOS) for the performing provider. When the previously submitted claim has a span date of service, providers must submit a claim correction for late charges with dates of service within the claim from and through date.

Example

Correct Action

Claim submitted for a member with:
- Single DOS 12/06/2022
- Late charges for the same performing provider on DOS 12/06/2022 were identified after initial claim was submitted

Wait for initial claim to finalize
Provider may complete claim correction to bill for identified late charges

Physical Therapy claim submitted for a member with:
- Claim span date of 07/01/2022 through 07/31/2022.
- Late charges were identified for 7/13/2022 for the same performing provider after initial claim was submitted.
- Claim line item DOS were not billed for 07/13/2022

Wait for initial claim to finalize
Provider may complete claim correction to bill for identified late charges

Note: All services from the same performing provider within a From and Through Span DOS must be submitted on the same claim. Late charges must be added through claim correct.

BCBSND will reject Medicaid Expansion claims if:

A claim is received for the same DOS by the same performing provider for another claim already on file
A claim is received with a DOS within another claim’s from and through date of service rendered by the same performing provider for another claim already on file

Coding & Billing Guidelines

When a late charge is identified by the billing provider, and the service(s) were rendered by the same performing provider for the same date of service or date span; the provider must correct the originally billed claim to report services rendered in addition to the services described on an original claim.

Professional Claims
Claim/Billing Frequency Type codes must be used to indicate the claim is a replacement/correction of a previously adjudicated (approved or denied) claim.

Completing a claim correction to add late charges:

Ensure the initial claim has been finalized prior to submitting a claim adjustment/correction.
Obtain the original claim number assigned by BCBSND for the initial claim.
Use Frequency Type 7 to indicate claim is an adjustment/replacement of a prior claim.
- Frequency Code 7 can be used for changes to diagnosis code, date of service, charges, add services or remove a line of the claim.

Institutional Claims
Providers must use Adjustment Bill Type XX7 to make changes to claims already submitted via paper, electronically, or through Availity Essentials.

Completing a claim correction to add late charges:

Ensure the initial claim has been finalized prior to submitting a claim adjustment/correction.
Obtain the original claim number assigned by BCBSND for the initial claim.
Use Adjustment Bill Type XX7 to indicate claim is an adjustment/replacement of a prior claim.
- XX7 can be used for changes to diagnosis code, date of service, charges, add services or remove a line of the claim.

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including incidental or mutually exclusive logic, payment integrity edits, and medical necessity.
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

History

Date

Updates

11/15/2024

Policy Created

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Fargo, N.D., 58121

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