Wiki Inpatient Medicare Part B

[RaeToll]

I appreciate any assistance with billing the secondary payer following Medicare Part B.


Primary payer is Medicare Part B
Secondary payer is Anthem BCBS

Medicare Part B was billed for outpatient services with TOB 0121.
Anthem was billed with TOB 0111.
Anthem denied payment as the claim amount did not match the EOB.

Is there something I should be adding to the Anthem claim indicating that only outpatient services were billed to Medicare Part B? Should I bill Anthem with TOB 0121 also?

 

[thomas7331]

This is probably something you're going to have to work out with Anthem. Was this claim billed to Medicare as outpatient because the patient did not have Part A coverage, or was it because the services were not approved by Medicare at the inpatient level of care? If it's due to the patient not having Part A coverage, then this denial sounds like it was an error on Anthem's since they should know that without Part A coverage the room and board charges would have been excluded from Medicare but should have been considered by the secondary payer. On the other hand, if Medicare denied the inpatient stay as not medically necessary, then those inpatient charges probably shouldn't be passed on to the secondary insurance as they would be provider liability, but you'll need to find out how Anthem wants them billed in a situation like that.

 

[RaeToll]

The patient does not have Part A coverage. I appreciate your input. We will be appealing this denial.