General
These are currently the most asked questions at our Provider Contact Center. Please read the Q&A below to see if we can help you with your inquiry.
- Does Medicare Part A or Part B pay for the vaccine for herpes zoster, Zostavx?
- How do I bill my Skilled Nursing Facility (SNF) claim when our patient was discharged to a hospital and returned to our facility the same day? The hospital claim is billed as an inpatient, same-day transfer.
- We have an inpatient who received a flu shot. How should we bill the flu shot when the patient is an inpatient?
- I'm billing a claim for conditional payment and it is suspended with reason code 31102. Where should I send my Explanation of Benefits (EOB) for reason code 31102?
- We have a patient who went to the emergency room from our skilled nursing facility. They returned to our facility the same day. When we billed our claim, it was rejected with reason code 38067 stating it was overlapping an outpatient claim. The emergency room and charges are excluded from SNF consolidated billing. How can we get our claim processed?
- What is the status on the claims that are being rejected for reason codes 38067 and 38068?
- How can I determine if I billed the correct patient status code on my claim?
Does Medicare Part A or Part B pay for the vaccine for herpes zoster, Zostavx?
Zostavax vaccine for herpes zoster is not covered under Medicare Part A or Part B. Zostavax vaccine is preventive and therefore would be covered under Medicare Part D. Please refer to MLN Matters Article SE0678 for clarification regarding the Zostavax vaccine.
(Question based on November 2008 top written inquiries)
Date Posted: 12/16/2008
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The SNF claim would need to be split-billed. For example:
SNF Stay: 11/01/08-11/31/08
Hospital Stay: 11/05/08 (inpatient, same-day transfer)
Billing Instructions:
The first SNF claim would be billed with
a. Date of Service: 11/01/08-11/05/2008
b. Patient Discharge Status 02
The second SNF claim would be billed with
a. Date of Service: 11/05/2008-11/30/2008
b. Admit Date 11/05/08
The hospital claim would need to be billed as a same day transfer.
a. Date of Service: 11/05/2008
b. Condition Code 40
c. Patient Discharge Status 03
NOTE: Split-billing the SNF claims will not work if the hospital does not apply the condition code 40.
(Question based on November 2008 top written inquiries)
Date Posted: 12/16/2008
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Influenza vaccines are payable on a Part B claim only. Therefore you would report the charges on either an ancillary claim or an outpatient claim, types of bill 12X, 13X, 22X, 23X, or 85X. You can access the CMS Preventive Service Quick Reference on Immunizations online.
(Question based on November 2008 top telephone inquiries)
Date Posted: 12/16/2008
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Please forward the requested EOB’s to the appropriate address below based on your contract area:
Highmark Medicare Services
Part A Claims Processing (DE) – MSP
PO Box 890417
Camp Hill, PA 17089-0385Highmark Medicare Services
Part A Claims Processing (MD/DC) - MSP
P.O. Box 890386
Camp Hill, PA 17089-0386Highmark Medicare Services
Part A Claims Processing (New Jersey) - MSP
P.O. Box 890420
Camp Hill, PA 17089-0420Highmark Medicare Services
Part A Claims Processing (PA) - MSP
P.O. Box 890385
Camp Hill, PA 17089-0385(Question based on October 2008 top written inquiries)
Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008
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Claims that are incorrectly rejected with reason code 38067 or 38068 should be resubmitted and will be suspended for manual review. If there is a true overlap situation, the claims will be returned for provider action. Highmark Medicare Services posted a 'What's New Article' on October 31, 2008 regarding reason codes 38067 and 38068.
(Question based on October 2008 top telephone inquiries)
Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008
What is the status on the claims that are being rejected for reason codes 38067 and 38068?
Claims that were incorrectly returned for reason codes 38067 and 38068 should be sent back for processing. Please be sure to delete and re-key all line items as covered if they were moved to the non-covered column. Should your claim be incorrectly returned again, please call the Customer Contact Center at 1-877-235-8048. You should advise the Customer Service Representative (CSR) that you already sent the claim back for processing and it has returned again in error. A CSR will document and escalate the information as appropriate.
(Question based on October 2008 written inquiries)
Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008
How can I determine if I billed the correct patient status code on my claim?
Prior to billing a claim, providers should verify where they discharged the patient by checking their medical records. If a provider's claim is sent to the RTP file or rejected indicating an incorrect patient status code was billed, providers should check with their medical records department to verify what the correct patient status code is. The Quick Reference Guide for Filing a Medicare Part A Claim has a list of patient status codes. If you need additional assistance, please call the customer contact center at f1-877-235-8048.
(Question based on September, October, & November 2008 top telephone inquiries)
Date Posted: 09/11/2008, Date Reviewed/Revised: 12/16/2008