Tuesday, April 5, 2011

Date of admission - inpatient claim submission



What date is considered the date of admission for an inpatient hospital stay?
MO HealthNet follows Medicare policy on the date of admission. Medicare policy is: "A patient of a hospital is considered an inpatient upon issuance of written doctor orders to that effect".

How does a provider submit an inpatient claim that requires a two-page claim for all the services?
If at all possible, the provider should list all the services on a single claim form. If this is not possible, the provider may bill the services on two claim forms. In field 80 on the first page of the claim, put “page 1 of 2”. In field 80 of the second page, put “page 2 of 2”. Staple the claims together prior to submission.

Does a provider have to submit a claim to Medicare for a patient who has exhausted his/her Medicare inpatient benefits and get a denial from Medicare before filing a claim to MO HealthNet?

Yes. MO HealthNet requires that a claim be filed to Medicare first before filing a claim to MO HealthNet. Once the denial has been received, a paper claim can be filed to MO HealthNet and a copy of the Medicare denial or exhausted benefit letter attached to it. The claim can be filed also using the X12 837 institutional claims transaction or the direct data entry inpatient or outpatient claim through the MO HealthNet Internet billing Web site, emomed.com. The range of dates on the claim to be filed to MO HealthNet must fall within the range of dates on the claim filed to Medicare. The denial code description should be visible on the Medicare denial or entered in the appropriate field(s) on the electronic claim form.

 A hospital wants a pre-certification for a pregnant woman for a medical condition unrelated to the pregnancy, e.g. mental health services. Should a pregnancy diagnosis code be reported?
HCE does not review most pre-certifications if the admitting or primary diagnosis code is related to pregnancy. Therefore, a diagnosis code relating to pregnancy should not be used as the admitting/primary diagnosis code. If the hospital stay is not related to pregnancy, it must be clear that the pregnancy is incidental to the admitting/primary diagnosis.

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