Opinion ID: 1301063
Heading Depth: 1
Heading Rank: 4

Heading: Patients and Procedures.

Text: D.P. and E.M. are two pediatric patients who received medically necessary hematology or oncology services in the hematology/oncology clinic at the Scott Pavilion. No doctor was directly involved in the treatment of either D.P. or E.M. with respect to the services relevant to this appeal. After providing services to D.P. and E.M., Children's billed Medicaid for the services on Form CMS-1450, which provides for the submission of claims for institutional services. With respect to D.P., certain claims were denied, at least in part, with the notation that '[p]ayment [was] adjusted due to a submission/billing error(s).' Other claims for laboratory work were paid as outpatient hospital services. With respect to E.M., who received chemotherapy, DHHS denied certain claims, at least in part, again noting that '[p]ayment [was] adjusted due to a submission/billing error(s)' and further noting that Children's had used an '[i]ncorrect claim form/format for this service.' Still other claims were denied with DHHS noting that `[p]ayment is denied when performed/billed by this type of provider' and that ' [t]his provider type/provider specialty may not bill this service.' As with D.P., claims for laboratory work were paid as outpatient hospital services.