Additional Response for Question 45
Provided by Jody Whitten 01.22.14
Attached are the combined questions. Jurisdiction specific examples have been left off…therefore I’ve copied and pasted the full answer to question 45 below:
45.(D) Recently suppliers are seeing denials in Region D for overlapping dates on TPN claims with two different remark codes:
Scenario ONE: Denials with OA – 18 and N111 for other adjustment/ duplicate claim with NO appeal rights. Every other claim is denying due to overlapping date and supplier has NO Appeal rights – What can we do? True duplicate claims do not have appeal rights. The supplier has to appeal the first submitted claim. They cannot keep resubmitting to extend appeal rights. If the claim is not a true duplicate, they can appeal stating this however if the claim has been submitted multiple times the duplicate denial would stand and does not extend the appeal rights.
Scenario TWO: Denials with CO-150 Contractual obligation for overlapping dates but with the MA01 remark allowing for appeal. All or some of the line items are denying for overlapping dates, however the claims are overturned in appeal. Sometimes the only items denied are the supply and administration kits due to overlapping dates (and not necessarily the formula or lipids).
Examples provided:
CCN 13031764308001: Inotropic Therapy
1/21-1/30/13 A4222 # 2 units $ 330.00 – denied OA-18
1/21-1/30/13 A4221 # 1 units $ 165.00 – denied OA-18
These denied as duplicate to claim below…and should be acceptable due to billed with ship date on 1/21/13
This is not a Noridian CCN so unable to review
CCN 1302879670331
1/21 – 1/23/13 # 28 units J2260 $ 3382.12 - denied OA 18 Drug denied on this claim and paid on the above claim – I believe the end date was corrected for drug in the above CCN. This claim allowed & paid 1/14- 1/23/13 # 1 units A4222.
This is not a Noridian CCN so unable to review
CCN No: 13113803215000
Denied Co -150 Payer deems the information submitted does not support this level of service. CCN 13113803215000 Noridian stated that these services have already paid for the month against invoice 501552 (Note: Inv. 501552 was for dates of usage 3/14/13 - 3/20/13 for 7 bags-shipped 3/8) Example - 7 bags were shipped on 3/15/13 for dates of usage dates 3/21/13-3/27/13 for the claim in question. For dates billed in March 2013 a total of # 28 units of TPN bags, #28TPN supply kits and #28 TPN admin kits were billed. How is this over utilization?
This is being corrected by Noridian and education given to adjustor.
CCN: 13115803776001
The pump denied OA 18 & N111 No appeal rights. No appeal right except
duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
DOS 4/21/13 denied for duplicate billing correctly. B9004 was paid to this supplier on CCN 13113-8032-21-000, remit date 050813. This is a correct denial, no appeal rights
CCN 13115803776001
Provider Note: This was part of a redetermination (Initial claim denied for overlapping datesOA-18). After the redetermination was made, claim was processed for payment and then the B9004 was the only line that denied OA-18.Our records do not indicate a prior payment for the 5th monthly rental for pump. Prior billed and paid is 12/21/12 (initial), 1/21/13, 2/21/13, 3/21/13 and 4/21/13 – which was denied in the above CCN claim as duplicate.
Same CCN as above
CCN: 12334827193000 Denied C0-150 & M25
M25 the information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.
This is being corrected by Noridian and education given to adjustor.
CCN 12334827193000
Noridian stated that these services have already paid for the month against invoice 457760\The ship date = 11/27 and the usage dates for the 3 bags is 12/4, 12/5, and 12/6. The units billed correlate with the 3 bags. And the lipids (b4185) correlate with 40 grams (4units) per each bag.
According to the POD requirements, this is billed correctly
NOTE: the provider of these services contacted Noridian CS and was given the following instruction: When I placed a call to Noridian for a better explanation, the customer service rep advised that this denied for overutilization and that it is determined as overlapping because we billed for several dates during that month. She advised that you can only be paid for one billing per month.
Same CCN as directly above.
Additional CCN’s that have denials due to overlapping dates or as a duplicate claim are:
CCN 13133857152000 – denied OA 18 duplicate
CCN 13119870712000 – denied OA 18 duplicate
CCN 13119870711000 – denied OA 18 duplicate
CCN 13142815128000 – denied Co-150….this one was billed with date spans consistent with the units…and therefore denied as overutilization. If allowed to have billed with usage dates we would have had a 3/25 claim for #3 bags of TPN, #3 supply kits, #3 Admin kits… and a 3/26 claim for Additional #3 bags of TPN with lipids, #3 supply kits and #3 Admin kits for a total of 6 days of administration or in other words…usage dates of 3/25 – 3/30….vs. ship dates of 3/25 and 3/26 allowed & paid 1/14-1/23/13 # 1 unit A4221.
•DOS 03/26/13-03/28/13
o3 units There cannot be 3 units allow between 3/27/13 and 3/28/13 only 1
oCorrectly denied as days are covered under two other DOS
•Paid DOS 03/25/13-03/27/13
oCCN 13120-8277-19-000
o3 units
•Paid DOS 032813-04/02/13
oCCN: 13170-8140-56-000
o6 units
Follow up question: In regard to Scenario One above, how should a supplier correct the claim with the OA-18 N111 denial with no appeal rights? These are not duplicate claims, as the examples provided should validate. Must we go through the appeal process?
Talk to you on Monday. Thanks
Jody Whitten
DME Supplier Education Consultant
Noridian Healthcare Solutions, LLC,
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