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
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Updates
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11/15/2023
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Policy Created
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3/27/2024
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This policy has been split into two different versions, a Commercial guideline and a Medicaid Expansion policy. The policy application section has been added to this policy for transparency.
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