Community Care Claim 667: A Case Study
We have reviewed Community Care claim nos. 242 and 667. As discussed more fully below, we recommend that Los Robles Hospital not pursue Claim 242 and that OUMC not pursue claim 667 as against Community Care.
A. Claim 242
1. Claim Facts
The patient was admitted to Los Robles Hospital and Medical Center (“Hospital”) through the ER following a DUI accident that was her fault on November 5, 2013. She was discharged the following day. The Artiva notes record that the patient’s Community Care policy number was provided by her husband over the phone on the day of admission. On November 22, 2013, the husband also provided Community Care’s billing address, phone number, and fax numbers. The Artiva notes indicate that on December 21, 2013, …show more content…
The notes also state that Hospital needed to receive a medpay exhaustion letter in order to submit the claim to the patient’s health insurance. The source of this requirement is not stated. On May 21, 2014, Community Care informed Hospital that the patient’s coverage had terminated and stated that the 120 day timely filing period had expired. On July 30, 2014, Hospital finally submitted a UB-04 to Community Care as the secondary payor, which was 266 days after the patient was discharged. On September 17, 2014, Community Care denied the claim for timely filing. The total billed charges are $59,819.44. Because the hospital does not participate in Community Care’s network, it is unclear what the expected payment would …show more content…
On September 16, 2015, OUMC called Community Care and was informed that the claim had been denied on September 9 due to OUMC being out of network and not having received authorization for the procedure (the patient’s plan only had contracted providers in the Tulsa area [Patrick, were you able to confirm this somewhere? I said in my email that there were likely providers in Tulsa since it is a big city but that was just speculation.). On September 30, OUMC submitted a first level appeal with the IB, medical records, and UB-04. The appeal requested a medical necessity review, and did not mention that the patient did not present with his insurance card. However, on November 12, a new first level appeal was submitted. This appeal discussed the fact that the Facility had received authorization, and gave the authorization number that had been provided by the
A. Claim 242
1. Claim Facts
The patient was admitted to Los Robles Hospital and Medical Center (“Hospital”) through the ER following a DUI accident that was her fault on November 5, 2013. She was discharged the following day. The Artiva notes record that the patient’s Community Care policy number was provided by her husband over the phone on the day of admission. On November 22, 2013, the husband also provided Community Care’s billing address, phone number, and fax numbers. The Artiva notes indicate that on December 21, 2013, …show more content…
The notes also state that Hospital needed to receive a medpay exhaustion letter in order to submit the claim to the patient’s health insurance. The source of this requirement is not stated. On May 21, 2014, Community Care informed Hospital that the patient’s coverage had terminated and stated that the 120 day timely filing period had expired. On July 30, 2014, Hospital finally submitted a UB-04 to Community Care as the secondary payor, which was 266 days after the patient was discharged. On September 17, 2014, Community Care denied the claim for timely filing. The total billed charges are $59,819.44. Because the hospital does not participate in Community Care’s network, it is unclear what the expected payment would …show more content…
On September 16, 2015, OUMC called Community Care and was informed that the claim had been denied on September 9 due to OUMC being out of network and not having received authorization for the procedure (the patient’s plan only had contracted providers in the Tulsa area [Patrick, were you able to confirm this somewhere? I said in my email that there were likely providers in Tulsa since it is a big city but that was just speculation.). On September 30, OUMC submitted a first level appeal with the IB, medical records, and UB-04. The appeal requested a medical necessity review, and did not mention that the patient did not present with his insurance card. However, on November 12, a new first level appeal was submitted. This appeal discussed the fact that the Facility had received authorization, and gave the authorization number that had been provided by the