During claims processing, we have been experiencing problems when trying to correlate professional services rendered to members during inpatient stays. As a reminder, you must populate the hospitalization date on the CMS-1500 (professional) claim form. We?ve found that providers often leave this field unpopulated when a surgery has been performed during an extended inpatient admission.
Claims submitted without this information when applicable could result in the following denial for no authorization: ?The patient?s coverage required an authorization for the reported service. Since the appropriate managed care record was not on file, no payment can be made.?
In this case, a corrected claim would be required for services to be reconsidered; submitting a claim investigation through the NaviNet® web portal would not constitute a corrected claim.
Please follow the instructions outlined below for electronic and paper claims submissions.
Electronic claims
837P
When billing electronically ? which is the preferred method ? please follow these guidelines:
- Loop 2300, Segment DTP when qualifier = 435 (Admission)
- – Required on all ambulance claims when the patient was known to be admitted to the hospital.
OR - – Required on all claims involving inpatient medical visits.
- Loop 2300, Segment DTP when qualifier = 374 (Discharge)
- – Required for inpatient claims when the patient was discharged from the facility and the discharge date is known.
Paper claims
CMS-1500 claim form
When submitting a paper claim, use Box 18 ? Hospitalization Dates Related to Current Services and follow the instructions from the National Uniform Claim Committee (NUCC) billing requirements:
- Enter the inpatient 6-digit (MM?DD?YY) or 8-digit (MM?DD?YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If the patient has not yet been discharged, leave the discharge date blank. This field is used when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
Example:
For more information, please refer to the 1500 Health Insurance Claim Form Reference Instruction Manual, which is available under the 1500 Claim Form tab on the NUCC website.
For more information about electronic claim submission guidelines, the appropriate HIPAA Transaction Standard Companion Guide for AmeriHealth New Jersey or AmeriHealth Pennsylvania, available on the Trading Partner Business Center.
If you have any questions about billing for professional services during an inpatient stay, please contact your Provider Partnership Associate or Network Coordinator.
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