San Francisco Health Plan Claims Billing: Inpatient Services, Facility Outpatient, Medical Supply, Duplicate Billings
San Francisco Health Plan Claims Billing Notes described below regard to some points not mentioned in the previous posts devoted to EDI requirements. Inpatient Services, Facility Outpatient, Medical Supply, Duplicate Billings notes are presented in general.
Inpatient Services
San Francisco Health Plan Claims Billing reimburses inpatient care, subject to authorization and notification requirements. Prior notification by the hospital to SFHP or the designated Medical Group is required for all inpatient admissions. Notification of admission is required before providing post stabilization care to a patient with an emergency condition. The hospital must request authorization for post stabilization care (AB 1203). SFHP does reimburse for authorized Administrative Days when correct Revenue Codes are used per Medi-Cal guidelines and rates.
The admission date determines all inpatient reimbursement terms. When admission dates bridge contract effective dates, the contracted rate will be applied to those dates on or after the contract effective date. Determination of inpatient status occurs at the date and time the admitting physician writes the order to admit the member to inpatient status and when the member’s clinical status meets SFHP’s criteria for inpatient care. No reimbursement will be made after a SFHP member terminates membership with the San Francisco Health Plan, even if the member is an inpatient in the hospital on the date of termination. SFHP reimburses inpatient care (except for Organ Tissue Procurement and Factor 8) at a single per-diem inclusive rate when prior authorization is approved and when notified within appropriate timeframes.
Complete the EDI 837 Institutional claim file or UB04 claim form using the appropriate inpatient services revenue codes and diagnosis codes. When applicable, enter the authorization number in box 63. All professional services should be billed within an EDI 837 Professional claim file or on a CMS 1500 claim form using the appropriate CPT/HCPCS and diagnosis codes.
Facility Outpatient Billing
Prior notification by the hospital to SFHP or the designated Medical Groups is required for all facility outpatient services. Complete the EDI 837 Institutional claim file or UB04 claim form using the appropriate outpatient facility HCPCS codes and diagnosis codes. If applicable, enter the authorization number in box 63. Professional services should be billed within an EDI 837 Professional claim file or on a CMS 1500 claim form using the appropriate CPT/HCPCS and diagnosis codes.
Medical Supply Billing Requirements
San Francisco Health Plan Claims Billing requires to submit medical supply claims not via EDI but as a paper claim via mail. The medical supply billing requirements, impact Durable Medical Equipment (DME) and Pharmacy providers, include:
- Discontinuing the use of local medical supply billing codes as of 10/01/14.
- HCPCS Level II codes are required for all disposable and incontinence medical supplies
- A Universal Product Number (UPN) is required for all contracted items
- Only product identification numbers listed in the Medi-Cal provider manual under “UPN” will be acceptable for billing purposes
- Invoice should include item description, manufacturer name, model number, catalog number, manufacturer suggested retail price (MSRP), if applicable
- Itemization of miscellaneous supply codes, etc.
Duplicate Billings
Identical services billed for the same date of service are considered duplicate billings, and only one, service will be reimbursed. SFHP uses the following fields to identify duplicate billing: member ID, dates of service, service codes and modifiers. If you are billing for multiple procedures or visits on the same date of service, ensure to include the appropriate modifiers, rendering provider NPI, and supporting documentation.