Blog # 1 – Medical Billing 101
ADF rejections can appear on error reports or as DF on RA reports when a claim has ineligible fee codes attached ie. special visit premiums (SVPs). SVPs are only eligible for payment with certain parent service codes and pursuant to the rules set out in the Schedule of Benefits. If a valid parent service is not billed with an SVP, or if a valid parent service is billed but not eligible for payment.
Including the incorrect fee code with the SVP code(s) could cause rejections and payment delays that could require a Remittance Advice Inquiry (RAI) which can take the ministry about 8 months to review.
Here are some examples of claims that could reject with ADF or DF:
An internal medicine physician bills a consult after being called in on the weekend at 6pm to see an inpatient and they were not at the hospital at that time.
C135A = the inpatient consult fee code when billed without premiums
C963A + C986A = corresponding SVP codes (travel + 1st person seen)
***SINCE YOU WILL BE ADDING SVP CODES TO THE CONSULT THE PREFIX OF THE CONSULT MUST CHANGE TO “A”. HERE IS HOW YOUR CLAIM SHOULD BE BILLED:
A135A + C963A + C986A
Here are a few other scenarios that could create this rejection:
* Billing the incorrect SVP codes that do not match the service date
(i.e. billing a weekend code on a weekday).
* Billing the travel code with the additional person(s) seen code
– the travel code is only eligible with the first person seen. If you leave the facility and get called back the travel + 1st person seen may be eligible again otherwise only the additional person(s) seen code would be eligible.
* Billing just the travel code alone is NOT eligible
– only the first person see or additional person(s) is eligible being billed alone.
Time is money 🙂
