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
April 6, 2021, to May 19, 2021, as originally billed.
You submitted a claim for payment to the Plan for inpatient service. The Plan denied full payment. The Plan
says the Medicare billing criteria were not met because an itemized bill was not received with the claim.
Maximus overturned the Plans denial for a lack of invoice information in the case file. The Plan requested a
reopen and provided the required information. The Plan noted that this claim denied because an itemized bill
had not been submitted. Once the itemized bill was received on January 4, 2022, the Plan completed their
review and determined the following:
The provider sent a corrected claim (IB) in the amount of $636,500.79. At the time of review the Plan did not
have this claim in their system. The original UB was in the amount of $630, 397.78, this claim is currently in system. This is a difference of $6,103.01.
The provider added $999.51 under revenue code 250, $2,008 was added under revenue code 391, revenue code
481 was a newly added revenue code to the IB in the amount of $2,753, and revenue code 771 was also added
in the amount of $343.00. Several items and services initially denied due to not having an itemized bill
have now been identified as routine items and services. The Plan continues to uphold the denial of the
routine items and services billed with denial code "G"; total denied amount is $10,516.16. As said previously
under revenue code 391 we were only able to deny one transfusion charge for unbundling in the amount of
$1,004.00, as the two remaining transfusion charges in the amount of $2,008 were approved as these charges
were not on the original UB. Please see attached Itemized Bill Summary of denied charges. Medication charges
under rev codes 250, 258 and 637, 636 were bundled under revenue code 250 on the original UB in the amount
of $429,913.76, there was $999.51 added to the corrected IB, and no charges removed. There were denied
medication charges with denial code "F' totaling $8,425.75, as we were unable to determine what these items
were. A charge of $312.87 HC Csr With Hcpc Rev 272 was denied with "F" as unable to determine the nature
of service and clarification of this charge is requested. Total charges denied for code F = $8,738.62. The
itemized bill is as follows: - Dates of service 4/7/2021 - 5/19/2021 HC RX 250 Pharmacy Shell (rev code 250)
in the amount of $3,222.25 were unable to be validated as there were no drug descriptions or J-codes listed on
the IB to clearly identify these pharmacy charges. These charges were denied with denial code F-not able to
determine nature of service and clarification is requested. - Dates of service 4/6/2021 - 5/7 2021 HC 636
Pharmacy Detail Coding (rev code 258) in the amount of $618.00 were unable to be validated as there were no
drug descriptions or J-codes listed on the IB to clearly identify these pharmacy charges. These charges were
denied with denial code F-not able to determine nature of service and clarification is requested. - Dates of
service 4/6/2021 - 5/19/2021 HC RX 637 Alt Medi A9270 Gy (rev code 637) in the amount of $4,010.50 were
unable to be validated as there were no drug descriptions or J-codes listed on the IB to clearly identify these
pharmacy charges. These charges were denied with denial code F-not able to determine nature of service and
clarification is requested. - Dates of service 4/21/2021 - 5/18/2021 HC RX 637/250 For SX & PX (rev code
637) in the amount $575.00 are not validated due to not having J codes to identify the medications and charges.
These charges were denied with denial code F-not able to determine nature of service and clarification is
requested. Additionally, after review of both the itemized bill and the medical records received, the
remaining denied charges totaling $611,142.50 initially denied for a missing itemized bill and/or missing
medical records are now approved. The Facility has recently provided the itemized bill allowing us to
identify and validate the charges utilizing both the itemized bill and medical records provided.
In summary, the Plan is upholding the denied charges in the total amount of $19,254.78. They are approving
charges in the amount of $611,142.50. The additional charges on the Itemized bill totaling $6,103.51 were also
approved. The total approved charges $617,246.01. The review finding resulted in a revised total
reimbursement amount of $103,326.51.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the original claim was denied due to lack of an itemized bill. Now that information was received as
stated above, the Plan processed the claim based on those charges billed that were allowed by Medicare.
Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee
from April 6, 2021, to May 19, 2021, as originally billed.