As previously communicated, when submitting a claim review request for facility pricing on the NaviNet web portal, please be specific when describing the reason for the claim review. To submit a claim review request, locate the finalized claim using the Claim Status Inquiry transaction, and then select the Claim Investigation link.

Follow the guidelines below to help expedite processing of your claim review requests.

Submission preparation

Prior to submitting a claim review request for facility pricing, take the following steps:

• Using the Claim Investigation Inquiry transaction, confirm that there is not an existing investigation for the same claim that may have been previously submitted by your office.
• Verify the line of business (LOB) for the member?s benefit plan, the member?s coverage effective date compared to the date of service (DOS), and the member?s eligibility for the service(s) performed.
• Review your AmeriHealth Agreement effective date and expected reimbursement.
• Review the admission date and discharge information. Note: Remittance is established by the date of admission, regardless of a change in the provider?s Agreement or member?s benefit plan during an inpatient stay. Refer to field 12 on the UB-04 claim form for the date of admission and fields 16 and 17 for the discharge status.

• Verify the status of the authorization, if applicable (i.e., pending vs. approved, level of care, dates of service, and service(s) performed).

In addition, please review the following:

• Modifiers. The application of modifier pricing is administered per Ambulatory Payment Classifications (APC)-based outpatient contracts only. AmeriHealth does not acknowledge modifiers if you are a facility that is contracted according to the outpatient fee schedule (i.e., not through APC [non-APC]).
• Quarterly fee schedule updates.* As outlined in your AmeriHealth Agreement, due to changes in clinical practice and/or modifications to standard coding systems, we may add, delete, and/or re-categorize the fee schedule for outpatient procedures. AmeriHealth provides a 30-day advanced written notice to facilities of such changes. It is imperative that these changes are reviewed to ensure accurate billing and claims reimbursement.
• Pharmacy fee schedule. Confirm if your facility is currently contracted per the Outpatient Cost-Based Pharmacy Fee Schedule.
• For APC facilities. In the event the Centers for Medicare & Medicaid Services (CMS) makes updates to APC Grouper/Pricer and/or Fee Schedules, AmeriHealth will update the APC Grouper/Pricer within 60 days of CMS publishing such updates. The parties agree, however, that retrospective changes made by CMS shall not apply.

*Quarterly fee schedule updates are not applicable to skilled nursing facilities.

Claim Investigation Submission

When submitting a claim review request for facility pricing variances, the following information must be included in order for AmeriHealth to research your request:

The inquiry must include certain information, depending on your reimbursement methodology:

• Diagnosis related group (DRG). If you are questioning the manner in which a DRG inpatient claim is paid, the inquiry must include the following:
• – expected DRG;
• – its base rate;
• – its weight;
• – adjustment factor;
• – whether you expect the inlier, outlier, or transfer rate.
• Per diem. If you are questioning the manner in which a per diem inpatient claim is paid, the inquiry must include the following:
• – revenue code(s);
• – number of days;
• – expected per diem rate.

If you are questioning the manner in which outpatient fee schedule claims are paid, the inquiry must include the following:

• procedure code(s);
• corresponding base rate (Note: Our fee schedules are updated quarterly; therefore, please ensure you are pulling the base rate from the fee schedule that corresponds with the claim DOS);
• adjustment factor.

If you are questioning the manner in which APC claims are paid, the inquiry must include the following:

• date of the APC version;
• adjustment factor.

Note: AmeriHealth currently receives hundreds of APC pricing inquiries per month that do not meet the criteria for adjustment because the pricing differential is due to CMS retrospective updates.

For more information

For instructions on using the Claim Investigation Submission transaction, please see our detailed user guide, which can be found in the NaviNet Resources section. This guide has been updated to reflect the guidelines mentioned above.

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