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Thursday, April 7, 2011

CAPITATED CLAIMS BILLED INCORRECTLY UNDER NON CAPITATED PAYOR ID

DESCRIPTION OF THE ISSUE
We billed all the Humana patients towards non capitated payor# 61102. For which we started receiving both capitation payments as well as fee-for-service payments incorrectly.

CONCEPT
Capitated patients should be billed only through capitated payor# which is 61101.

SOLUTION
We segregated both capitated and non capitated patients by identifying the plans through card copies as well as through online verifications.  Capitated claims were transmitted to the payor#61101 and non-capitated claims were transmitted to the payor#61102.  Refunds for fee-for-service payments were initiated voluntarily from our end with the provider’s
consent.

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