Timely Filing & Admission
What happens when a claim is reaches 90 days after receipt while still in-house?
Adjudication reason: Admission exceeded 90 days and the patient is now discharged
What happens if the billed date of service doesn’t match the medical record?
Adjudication reason: billing date discrepancy
What happens when services are rendered by a non-contracted physician?
Adjudication reason: MD does not have a contract at this time, physicians name is added on the line note and claim is placed under contracted negotiation status for leadership review (If the claim pertains to MBB, then the claim is placed in Denied status, not contract negotiation).
What denial reason is used when the patient is registered with insurance?
Insurance
Are services at non-BHSF hospitals reimbursed?
No, the claim is denied or returned to provider.
What is the deadline for submitting claims from the discharge date?
180 days from encounter discharge DOS
What is the denial reason when there’s no supporting documentation in the medical record?
Adjudication reason: No doc found to support MR
What does “CAP MET” mean when JDA auto populates?
JDA will auto populate CAP MET if the agreement has a cap per encounter.
What happens when a patient has made a payment over $1,000?
Adjudication reason: payment made to account, bill patient.
What is the rule for direct admits from a non-Baptist Health hospital?
Claim is denied.
What is the denial reason if a claim is submitted more than 180 days after discharge?
Adjudication reason: Not submitted within 180 days of service
What happens when the CPT code is no longer in use?
CPT line is denied, a new line is added with the correct CPT and adjudication reason: CPT code corrected to correlate with admission status
What happens if there’s no agreement for the facility billed?
Adjudication reason: No agreement for facility billed
Rendering Name: MBB@MBB
Line note comment: @BHM
What does “Not qualified as unfunded” mean?
The provider may appeal the denial if documentation of three attempts to bill the patient is submitted.
What is the denial reason for Interventional Cardiology cases labeled as STEMI?
Adjudication reason: Stemi Case
In SF, where are the admission and discharge dates displayed?
Located at the bottom left corner of the SF screen
What is done if a CPT line does not generate a price and the calculation summary reflects $0 in billed charges?
Adjudicaiton Reason: Charges included in global fees.