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As previously communicated, during the transition to our new claims
processing platform, there was a change in the display of reimbursement for
multiple outpatient surgeries for Indemnity/Traditional, Federal Employee
Program (FEP), and Host BlueCard® claims. In addition, there was
a change in display for inpatient stays for commercial and Medicare Advantage
claims (excludes Host BlueCard claims). Please note that regardless of payment
methodology (i.e., per diem or diagnosis related group [DRG]), the
reimbursement for services is displayed across all claim lines.
Outpatient surgeries
- Claims processed on the previous platform. Reimbursement for
multiple outpatient surgical procedures were rolled up and displayed on one
payment line, as shown below.
| Claim ID | Claim line | Rev
code | Procedure code | Contracted
rate | Reimbursement |
| 1234 | 1 | 360 | 23130 | $100 x 2.5 = $250 | $375.00 |
| 1234 | 2 | 369 | 23156 | $50 x 2.5 = $125 | $0.00 |
- Claims processed on the new platform. Reimbursement for multiple
outpatient surgical procedures are displayed on two or more separate payment
lines, as shown below.
| Claim ID | Claim line | Rev
code | Procedure code | Contracted
rate | Reimbursement |
| 1234 | 1 | 360 | 23130 | $100 x 2.5 = $250 | $250.00 |
| 1234 | 2 | 369 | 23156 | $50 x 2.5 = $125 | $125.00 |
Inpatient stays
- Claims processed on the previous platform. Reimbursement for an
inpatient stay was rolled up and displayed on one payment line, as shown
below.
| Claim ID | Claim line | Rev
code | Units of service | Charges | Contracted rate | Reimbursement |
| 0011 | 1 | 171 | 1 | $3,000 | $47 per diem | $47.00 |
| 0011 | 2 | 174 | 1 | $6,000 | $3,489 per diem | $3,489.00 |
| 0011 | 3 | 300 | 5 | $1,000 | ? | $0.00 |
| 0011 | 4 | 636 | 10 | $2,000 | ? | $0.00 |
|
Total: |
$12,000 |
$3,536.00 |
$3,536.00 |
- Claims processed on the new platform. Reimbursement for an inpatient
stay is displayed on two or more separate payment lines, as shown below.
| Claim ID | Claim line | Rev
code | Units of service | Charges | Contracted rate | Reimbursement |
| 0011 | 1 | 171 | 1 | $3,000 | $47 per diem | $884.00 |
| 0011 | 2 | 174 | 1 | $6,000 | $3,489 per diem | $1,768.00 |
| 0011 | 3 | 300 | 5 | $1,000 | ? | $294.67 |
| 0011 | 4 | 636 | 10 | $2,000 | ? | $589.33 |
|
Total: |
$12,000 |
$3,536.00 |
$3,536.00 |
For more information about changes in the display of reimbursement, please
contact your Network Coordinator.
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