Reminder: Inpatient commercial claim denials
If your inpatient claim is denied in full, your next steps will depend on the reason for the denial.
- Late Authorizations/No Authorizations If your UM letter states a 30% penalty should apply and you received a 100% denial, contact Anthem to dispute the underpayment.
- Inappropriate Setting/Inappropriate Level of Care: If your UM letter states a 30% penalty should apply and you received a 100% denial, contact Anthem to dispute the underpayment.
- Not Medically Necessary (NMN): Provider can appeal NMN denial until appeal options are exhausted. Member is held harmless.
For any of these denial reasons, it is inappropriate to re-bill an outpatient claim for ancillary services rendered in the inpatient setting for commercial polices. This includes but is not limited to Emergency Department, Imaging, Laboratory services, Specialty Pharmacy, Surgeries.
Claims should be coded and billed based on the medical record and the physician order.
If claim is billed as Inpatient bill type in error:
- A frequency type 8 (void) of the Inpatient claim must be received first by the provider, or in conjunction with a frequency type 1 (original) outpatient claim before the outpatient bill type claim will be processed. This can be done electronically or with a PAR (Provider Adjustment Request) Form. Further instructions are in the Ohio provider manual.
For complete information on electronic claims processing procedures, visit our EDI website.
This update does not apply to Medicare and Medicaid.
February 2019 Anthem Ohio Provider Newsletter