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Changes in reimbursement display

June 1, 2016

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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 IDClaim lineRev codeProcedure codeContracted rateReimbursement
    1234136023130$100 x 2.5 = $250$375.00
    1234236923156$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 IDClaim lineRev codeProcedure codeContracted rateReimbursement
    1234136023130$100 x 2.5 = $250$250.00
    1234236923156$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 IDClaim lineRev codeUnits of serviceChargesContracted rateReimbursement
    001111711$3,000$47 per diem$47.00
    001121741$6,000$3,489 per diem$3,489.00
    001133005$1,000?$0.00
    0011463610$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 IDClaim lineRev codeUnits of serviceChargesContracted rateReimbursement
    001111711$3,000$47 per diem$884.00
    001121741$6,000$3,489 per diem$1,768.00
    001133005$1,000?$294.67
    0011463610$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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