S5102 Adult day health care change to billing procedure

We are writing to inform you about an important change in our billing policy regarding S5102, Adult day health care. S5102 is a per diem code. Care providers may bill only one unit per day per member. Effective from November 1, 2024, HealthKeepers, Inc. will begin denying claims for S5102 when the units billed do not exactly match the date span. Previously we announced an earlier date.

For example, if a care provider bills for a date of service (DOS) covering May 22 through May 26, equating to five days, then the care provider must bill exactly five units. Any claims not billed with the precise unit amount for the date span billed will be denied. The Explanation of Benefits (EOB) will note this as a Q64 denial — Service dates do not match units billed. Additionally, this billing discrepancy will trigger a Claim Adjustment Reason Code (CARC) 16 — Claim/service lacks information or has submission/billing error(s).

We encourage all care providers to review their billing practices for S5102 to ensure that unit billing corresponds exactly with the dates of service. This change is crucial in preventing claim denials. You are valued for the care you provide for our members, and we want to support you in getting your claims paid correctly.

If you have any questions about this communication, contact Provider Services at 800-901-0020, your regional provider relationship management representative, or the team at valtsspr@anthem.com.