Please note the following billing reminders for hospitals.
Quarterly fee schedule updates for all
hospitals
As outlined in your Hospital Agreement (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.
Independence provides a 30-day written advance notice to facilities of such
changes. It is imperative that these changes are reviewed to ensure accurate
billing and claims reimbursement.
If a particular outpatient procedure is not listed on the applicable fee
schedule, but we agree that it is a covered service, the following pricing
rules will apply:
- Surgical services:
Independence will establish a fee
for the procedure in question, based on the current fees for similar services.
- Non-surgical services:
Payment will be made based on
the applicable ?Percentage of Charges? until a fee is established.
Independence or its authorized representative has the right to review,
within reason and with timely notice to the hospital, medical records
pertaining to an outpatient service provided to members subject to the terms
and conditions within your Agreement. In some instances, this may be necessary
in establishing a fee for services rendered.
For hospitals contracted under APC: Proper
billing practices
On January 1, 2012, Ambulatory Payment Classifications (APC) reimbursement
was added to your Agreement for certain Independence products. According to
that Agreement, the APC Grouper/Pricer and Fee Schedules published and
distributed by the Centers for Medicare & Medicaid Services (CMS) are used to
determine reimbursement. The reimbursement amount is the product of the CMS APC
Pricer amount (or fee schedule amount) and the CMS Pricer Adjustment
Factor.
Reimbursement
As of January 2016, CMS implemented updates to the Hospital Outpatient
Prospective Payment System, OPPS (APC Pricer). It is important that you have
the most current version of the pricing application to ensure compliant billing
practices. Use of the inappropriate version may result in inaccurate
reimbursement.
Claim submission
For services applicable to APC reimbursement, when a provider has more than
one National Provider Identifier (NPI) based on the specialty of service(s)
they provide, he or she must use the NPI and coordinating taxonomy code that is
specific to acute-care services. This enables the accurate application of the
provider?s contractual business arrangements with Independence. Failure to
submit claims with the applicable NPI and correct correlating taxonomy code may
result in incorrect claim processing and/or payment delays.
Please review the following examples and share this information with your
billing staff/vendor.
| Incorrect billing practice | Correct billing
practice |
Revenue/ procedure code billed | 0324/71023
(Radiology ? Diagnostic/Diagnostic Radiology) | 0324/71023 (Radiology ?
Diagnostic/Diagnostic Radiology) |
Billing NPI | 12345XXXXX | 11223XXXXX
|
Specialty description | Psychology,
Clinical | Hospital ? Acute Care |
Taxonomy
code | 103T00000X | 282N00000X |
Taxonomy description | Psychology, Clinical
| Hospital – Acute Care |
For hospitals not contracted under APC: Modifier pricing
If you are a facility that is contracted according to the outpatient fee
schedule, meaning non-APC reimbursement, Independence
does not acknowledge modifiers. The application of modifier pricing is
administered on APC-based outpatient contracts only.
If you have any questions about these important billing reminders, please
contact your Network Coordinator.