Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 3, 2021, to December 16, 2021.
You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional documentation. The Plan notes that the Pricing Sheet, IB summary and list of approved charges were submitted with the reopen which support the Plans original denial. The Plan states that this claim on July 11, 2022, due to the facility not providing a detailed line by Line itemized bill for review. Once the itemized bill was received on October 25, 2022, the Plan several items and services initially denied due to not having an itemized bill were identified as being inclusive to either Room and Board or inclusive to a Procedure. These charges totaled $155,881.57 and were denied with denial code "G". The Plan provided the IB Summary for a list of denied charges. After a second review, services initially denied due to not having an itemized bill are now being denied with denial codes "B" for no documentation of service. The "B" code denial charges totaled $2,710.08 and are Guide Duoflex Spring-Wire $80.24, Kit Bio-Prep Bone Preparation $634.92 and Vasopressin Per 1ml $1994.92. Medical records received appear to be incomplete, and to date we still do not have documentation to support these charges, therefore we will continue to uphold the items and services denied with denial code "B" - no documentation of service. The Plan further states during the audit of this claim, full and complete medical records were requested multiple times November 17, 2022, and November 23, 2022, however the complete medical records were not received. At the time the appeal was sent to Maximus, the Plan continued to uphold the items denied with denial code "B" for no documentation of service which consist of: Guide Duoflex Spring-Wire $80.24, Kit Bio-Prep Bone Preparation $634.92 and Vasopressin Per 1ml $1994.92, totaling $2,710.08. Additionally, after review of both the itemized bill and the limited medical records received, the remaining denied charges totaling $1,155,536.54 initially denied for a missing itemized bill were approved by the Plan. The Plan states the facility provided the itemized bill allowing the Plan to identify and validate the charges utilizing both the itemized bill and medical records provided. In conclusion the Plan approved charges in the amount of $1,155,821.54. The Plan upheld charges in the amount of $158,591.65.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, after several reviews of the claim and requests for additional medical records, the Plan ultimately paid all but $158,591.65 due to errors on the claim regarding the billing of services whose payment was already included in the facility claim and/or the lack of a complete set of medical records to determine coverage. Medicare rules for coverage of this claim as it was originally billed were not met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 3, 2021, to December 16, 2021, in the remaining amount of $158,591.65.