Wiki Billing fee for service to global payers

[KELLI]

Can someone please clarify if there is any documentation to support that if we have a global contract with a payer we should only bill the services we will be paid for?

For example in the Urgent Care we are billing S9083 global code but are still being asked to bill out the x-rays even though we know we are only getting reimbursed for S9083 and the x-rays are being denied. I was always under the impression that we should be billing out clean claims and not for services we are not contracted for payment. Can someone please assist me?

Thank you

 

[thomas7331]

Because the contract is your provider's private agreement with the payer, the only way to know whether or not you are in compliance with the agreement would be to review the language in the contract. In my experience, the goal of most payer contracts is primarily to ensure that claims are reimbursed correctly according to the rates agree upon and that members are billed appropriately, so if charges you are not submitting are not resulting in incorrect payments or bills to members, then this is not likely to be a issue with the payer. But then again, the contract may contain language instructing you on how the claims should be billed. My recommendation would be to review the contract first and then the payer's published policies (most contracts require providers to follow the policies) and if after that you still don't find an answer, contact your payer representative and look at some claim examples together to make sure they align with the payer's requirements for correct billing.