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PHP level

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dedwards:
Hello,
I am trying to get set up to bill Medicare Part A claims for our PHP level day treatment clients.  The code we use (and receive payment) for Medicaid is H0035.  I've been told Medicare does not pay for H codes, but we're told by Medicaid that they don't pay for this particular service until Medicare pays first. Hope someone can help me before I pull my hair out!
Thank you so much,
Debbie

Michele:
I'm going to go out on a limb here, but I don't think Medicare covers those services, and I think you need to bill it out to Medicaid using the code that indicates that.  I'm not sure what state you are in, but in NY we would send it in with a 31 in the other insurance box to indicate that the  patient has Medicare but that the services being billed are not a covered service by Medicare and therefore there was no payment, so we are billing Medicaid.

Hope that is helpful.

Michele

dedwards:
Hi,
Thank you for your help.  I'm supposed to be working with our software vendor tomorrow to do a test run on Medicare Part A, so I'm going to call Medicare (AL) one more time today to try to get them to answer some questions.  I did get the UB04 form book, and it has been very helpful.
I do have a few questions though that I'm hoping someone could help me understand.
1.  In Box 42, how do we determine if PHP is less intensive (rev. code 0912 or 0913)? 
2.  In Box 45 service date:  I'm billing for a week's (5 days) service.  So, I think I would put 5 units in Box 46, but is the service date for the beginning day since the units are for more than one day?
3.  Box 47:  Is this total charge the charge for each unit or a total of all units?
4.  We will be billing Medicaid as secondary.  Is Box 50B the only place I indicate this?
I really appreciate all your help.  Our vendor nor Medicare has been very much help, so I'm winging it on my own!
Thanks again,
Debbie

Michele:
Glad the book has been helpful. 

1.  Only the facility providing the service can determine if the treatment is intensive.  I'm sure there are guidelines to meet, but I'm not familiar with them. 

2.  Yes, you would start with the beginning date.

3.  Total for all units

4.  Yes 50B would be where you report the 2ndary info.

Sorry for the delay in answering, I've had a couple rough days!  :(

Michele

dedwards:
Hi,
Can you believe I'm still working on getting our PHP claims accepted by Medicare!  Our one bill we've been trying to get to go through for months has finally made it through the Clearing House (McKesson), then it was rejected by Medicare.  Their reason was that there was not a discharge date.  Can you tell where that information goes on the claim?
I have found the UB04 book very helpful, but I'm not sure about this since our clients are not actually discharged but come to our facility daily for PHP.
Thank you so much for your help!

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