Reminder: Inpatient/outpatient Commercial claim denials
Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. would like to remind you of the procedures to follow for inpatient claim denials for our Commercial lines of business:
- If claim is billed as inpatient bill type in error, a replacement bill xx7 is a replacement of the same type of bill (ex. x11 and x17, or x31 and x37; you may not use a x37 to replace a x11 or a x17 to replace a x31).
- If you are changing the bill type from inpatient to outpatient or outpatient to inpatient, the original claim will need 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 included in the provider manual.
It is inappropriate to re-bill an outpatient claim when receiving a denial/upheld appeal response 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, and surgeries.
Claims should be coded and billed based on the medical record and the physician order.
For complete information on electronic claims processing procedures, visit the Electronic Data Interchange (EDI) page on our website.
Note: This update does not apply to Medicaid or Medicare Advantage.
August 2022 Anthem Provider News - Virginia