Tips for Verifying Facility Pricing Part II: When Claims Are Denied

Highmark has seen an uptick in facility claim denials, along with an increased volume of claim inquiries regarding facility pricing. 

We know it can be frustrating when claims are denied or reimbursement doesn’t meet your expectations.

By using the checklists below, you’ll have the tools to correct claims quickly, avoid submitting unnecessary inquiries, and, ultimately, improve processing of your facility claims. 

I. Common Denial Scenarios and How to Respond

• Services Not Covered/Benefits Exhausted: Re-verify eligibility and benefit limits.
• Authorization/Referral Missing: Confirm authorization was obtained and submitted.
• Duplicate Claim: Verify if the claim was previously paid or denied.
• Incorrect/Invalid Coding: Re-evaluate CPT, ICD-10, and modifier usage against coding guidelines.
• Not Medically Necessary: Review medical records for documentation supporting the necessity of the service.
• Missing/Incorrect Provider Information: Verify that your NPI, tax ID, and taxonomy align with the services you are billing.

II. Reimbursement Methodologies for Inpatient Claims: What to Verify

• Diagnosis Related Grouping (DRG) Reimbursement

  • What’s your expected DRG?
  • Which DRG version are you using for your claim?
  • What DRG weight are you using to calculate reimbursement? Make sure it corresponds to the correct version and the DRG you are expecting.

• Inpatient Per Diem Reimbursement

  • Does the revenue code(s) match the services you are billing and your contract?
  • What is the expected per diem rate? Does it match your contractual rate?
  • Compare dates of service on your claim vs. your rates effective dates.

III. Reimbursement Methodologies for Outpatient Claims: What to Verify

• General Outpatient Claims

  • Check if the procedure code(s) are valid for the services you are billing.
  • Evaluate if the revenue code and procedure code are valid to be billed together. 
  • Are there any missing modifiers required for the services you are billing?

• Ambulatory Payment Classification (APC) Claims and Ambulatory Surgical Centers (ASCs) Claims

  • Do the APC weights align with the APC version you are using?
  • Is the Wage Index the correct one for the dates on your claim?
  • Outpatient RCC (Ratio Cost to Charge) Factors: Is your claim expected to calculate an outlier? If so, are you using the correct RCC factor for the dates on your claim?
  • Did you verify the Medicare APC update schedule available on Availity?
  • Not getting the pricing you expected? Do your contractual terms limit the allowance for eligible charges?

IV. When to Submit an Internal Inquiry to Highmark

• You have thoroughly completed all steps in the above checklists and still cannot resolve the claim issue.
• You require clarification on a specific Highmark policy or guideline that is not readily available.
• You have submitted corrections/appeals, and the issue remains unresolved after a reasonable timeframe.
• When submitting an inquiry:
  • Include all necessary supporting documents (e.g., medical records, operative reports, appeal letters) for the specific service or claim type.
  • Provide what payment you are expecting and the supporting calculation, factors, rates, and documentation you are using to support your case.