Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay further reimbursement for inpatient care provided to the enrollee from March 14, 2021, to April 27, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says based on the medical records provided the services billed do not support the services provided. Maximus administratively overturned the Plans denial for a lack of medical records and claim information in the case file. The Plan requested a reopen and provided the required records and itemized bill for review.
The Plan demonstrated that the appeal states the diagnosis related group (DRG) for this claim was reassigned from 064 to 066. However, the submitted DRG is 064 and the cost outlier payment was initially recouped due to the provider not submitting the medical records needed to perform a Cost Outlier review of the claim. Initially the claim was denied on April 8, 2022, due to the facility not providing a detailed line by line itemized bill for review. The total claim charges were $465,418.20. Once the itemized bill was received on August 17, 2022, the Plan was able to review the claim and determined 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 $15,027.80. These items and services were determined to be inclusive to either room and board or the procedure and not separately reimbursed. The Plan provided the Itemized Bill Summary of denied and approved charges with the reopen request. Additionally, medical records received were incomplete. To date the Plan still does not have documentation to support multiple charges and therefore continues to uphold the items and services denied with denial code B for no documentation of service. The Plan show the charges denied with Denial code B for no documentation of service for a total $34,651.00. The Plan also attached an Itemized Bill Summary of denied and approved charges. The Plan has concluded and provided documentation to show the remaining denied charges totaling $415,739.40 initially denied for a missing itemized bill and/or missing medical records are now approved. The Plan notes the facility recently provided the itemized bill allowing us to identify and validate the charges utilizing both the itemized bill and medical records provided. The Plan is upholding the denied charges in the total amount of $49,678.80. The Plan approved charges in the amount of $415,739.40. The review finding resulted in a revised total reimbursement amount of $55,810.59
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. Providers must also submit medical records that support the itemized billed submitted for payment. In this case, we now find the Plan has provided the documentation required to support their revised decision, as additional information was received by the Plan since the original denial.
Based on this information, we decided that the Plan does not have to pay additional reimbursement for inpatient care provided to the enrollee from March 14, 2021, to April 27, 2021.