Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care billed to the enrollee from January 7, 2022, to
February 10, 2022, as originally billed.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned
the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that
initially claim was denied due to facility not providing complete medical records and detailed line by line
itemized bill for review.
The medical records were missing the physician orders. Without the orders and itemized bill, we were unable
to validate any of the charges billed by the provider. Total claim charges were $475,071.65. On appeal provider
submitted the itemized bill and the orders. Due to an oversight the orders were not reviewed as part of the
appeal and the claim was upheld as missing documents. Once we realized the error, the case was properly
reviewed. We completed the review and determined the following: We are approving charges totaling
$345,479.25. After review of both the itemized bill and the medical records received, the denied charges
totaling $345,479.25 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 which were submitted with the reopen request.
Several items and services initially denied due to not having an itemized bill and/or missing medical records
are upheld. The Plan upheld or denied charges in the total amount of $129,592.40. Several items and services
have now been identified as routine items and services. The Plan upheld the denial routine items and services
billed. The denial code "G", amount denied $25,533.60. These items and services were determined to be
inclusive to either room and board or the procedure charge and are not separately reimbursed.
The Plan also identified several services as administrative denials. For "VENT & MANAGE, EAC SUBSQ.
DAY "billed on date of service January 10, 2022, in the amount of $2,146.00, this charge is upheld with denial
code "H" for administrative, as credit for vent management was already given under VENT & MANAGE
INITIAL DAY also billed on date of service January 10, 2022, in the amount of $2,588.00. The provider
cannot bill for VENT & MANAGE INITIAL DAY and VENT & MANAGE, EAC SUBSQ. DAY on same
date of service as this would be charging for the same service type twice on the same day. A subsequent vent
charge should appear on days following the first day vent was initiated. The Plan states that "PACU PHASE II
C 0-30 MINUTES" billed on date of service February 4, 2022, in the amount of $175.00, and "PACU PHASE
II C EA ADD'L 15 MINUTES" billed on date of service February 4, 2022, in the amount of $93.00 were
denied under denial code "B" for missing documentation. These items were unable to be validated due to
missing documentation. The Plan further states Intensive care unit level room charges totaling $101,644.80
were identified as an inappropriate with denial code "O". Charges for room and care or intensive care from
January 25, 2022, to February 9, 2022, were modified to Medical Surgical rate of care as the enrollee met
criteria for Medical Surgical Care on these dates of service. The review findings resulted in a revised total
reimbursement amount of $43,314.16. This translates to the provider receiving further reimbursement of
$3,840.55.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, portions of this claim were denied due to inappropriate Medicare billing
and/or a lack of documentation to support the services billed. Medicare rules for coverage of this claim as
originally billed have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care
billed to the enrollee from January 7, 2022, to February 10, 2022, as originally billed.