Reminder: Inpatient/outpatient commercial claim denials
Anthem would like to remind you of the procedures to follow if an inpatient claim is denied.
If a claim is billed with an inpatient bill type in error:
A replacement bill xx7 is a replacement of the same type of bill (example: x11 and x17 or x31 and x37; you may not use an x37 to replace an x11 or an x17 to replace an x31)
- If you are changing the bill type from inpatient to outpatient, or from outpatient to inpatient, the original claim needs to be voided by using a frequency type 8 (void).
- The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
- This can be done electronically or with a provider adjustment request (PAR) form.
- Further instructions are available in the provider manual.
It is inappropriate to re-bill commercial outpatient claims when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting. This includes but is not limited to emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.
Claims should be coded and billed based on the medical record and the physician’s order.
For complete information on electronic claims processing procedures, visit our EDI website.
August 2022 Anthem Maine Provider News