Inpatient behavioral health authorized and billed code discrepancies

Anthem Blue Cross and Blue Shield embraces opportunities to foster collaboration efforts with our care provider partners to help ensure proper coding and payment of claims. As part of state reporting, we regularly review inpatient behavioral health code utilization. During this process it was recently noted that claims were submitted for behavioral health services that were not authorized. Prior authorization was granted for services under one diagnosis (designated to pay per diem or DRG), and a claim was made for payment under a diagnosis that fell in the opposite group (DRG or per diem). This change can lead to a significant difference in reimbursement.

This letter is sent as a reminder that, per the Indiana Health Coverage Programs (IHCP) Provider References Module for Behavioral Health Services (p. 31) and in accordance with 405 IAC 5-3-3 and 405 IAC 5-3-8:

• Providers must submit inpatient claims using the revenue code that has been authorized for the admission. The IHCP does not reimburse providers for days that are not approved for prior authorization.

Reimbursement is not allowed for revenue codes that have not been authorized. Billing diagnoses must be appropriate for the submitted revenue code. Billing codes other than those with prior authorization will result in denial of the associated claim.

We are grateful for your care of our members and look forward to continued collaboration.