As previously communicated through Partners in Health
UpdateSM and published in the Provider Manual for
Participating Professional Providers, AmeriHealth requires that
professional claims be billed on one CMS-1500 claim form or electronic 837P
transaction when two or more services are performed for the same patient, by
the same performing provider, and on the same date of service. The only
exception would be when we specifically require services to be billed on
separate claims based on an AmeriHealth policy (i.e., assistant or co-surgery
claims). Claims submitted otherwise are considered split-billed claims when
there is no policy that requires billing on separate claims.
Split-billed claims
Claims are considered split-billed when more than one claim is submitted for
payment for two or more services performed for the same patient, by the same
performing provider, and on the same date of service and there is no policy to
support split-billing. Some examples of split-billing include:
- two or more procedures or services performed by the same provider, on the
same date of service, on the same patient, submitted on more than one claim
form;
- services included in the primary services and procedures as part of the
expected services for the codes billed on separate claim forms.
Providers must bill for all services performed on the same day for the same
patient on a single claim form. Failure to do so prohibits the application of
all necessary edits and/or adjudication logic when processing the claim. As a
result, claims may be under- or over-paid and member liability may be under- or
over-stated.
Claims correction
As a reminder, if more than one CMS-1500 claim form or electronic 837P
transaction is received for services performed on the same patient, by the same
performing provider, and on the same date of service as a previously submitted
claim, and there is no policy to support split-billing, we will adjust all
individually submitted claims to deny. Providers will be required to submit the
split-billed services as a single, new claim for payment consideration. Also,
when submitting a paper claim that requires more than one CMS-1500 claim form,
only the last claim form should be totaled for multiple services performed on
the same patient, by the same performing provider, and on the same date of
service. On all other claim forms associated with the multiple-billed claim,
the Total Charge field should be left blank.
To the extent that service(s) for which there is no policy to support
split-billing is inadvertently omitted from a previously submitted claim, the
previous claim should be corrected. To submit a corrected claim, use the Claims
Investigation transaction on the NaviNet® web portal. Please do
not submit a separate claim for the omitted services, as that will create a
split-billed claim and all individually submitted claims will be adjusted to
deny.
We advise you to share this information with your clearinghouse to ensure
that claims for multiple billable services are being submitted correctly.
NaviNet is a registered trademark of NaviNet, Inc.