During the transition to our new claims processing platform, there was a change in the display of reimbursement for multiple outpatient surgeries and inpatient stays for AmeriHealth New Jersey Comprehensive Major Medical (CMM) claims. In addition, there was a change in display for inpatient stays for commercial and Medicare Advantage 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	0360	23130	$100 x 2.5 = $250	$375.00
  1234	2	0369	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	0360	23130	$100 x 2.5 = $250	$250.00
  1234	2	0369	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 Provider Partnership Associate or Network Coordinator.

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