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Elizabeth M. Whitehorn, Director

Rejecting in Error

HFS System Issue:

Hospital outpatient fee-for-service physical therapy and occupational therapy services are either paying inappropriately or rejecting in error when billed by hospitals under the same provider number.

Problem:

Claims are utilizing the first prior approval on file for the provider number, recipient number and date of service billed regardless of the modifier (GP vs. GO) used on the claim.  Additionally, when both PT and OT priors exist for the same provider number, recipient number and overlapping date(s) of service, claims reject after the first prior approval on file has been fully decremented, as the system is not recognizing any additional prior approvals on file.  These issues are causing one or both of the following problems:

  1. Claims are paying incorrectly when no prior approval exists for the discipline billed but a prior approval authorization is on file for the other discipline.   For example, a physical therapy claim having no prior approval authorization may pay from the occupational therapy prior approval authorization.
  2. Claims are rejecting with the D36 error code when the system has incorrectly applied the total number of visits billed for physical and occupational therapy toward a single prior approval on file and does not read any additional prior approval on file for the other discipline when authorized for the same provider number.

Providers Impacted:

Hospitals billing physical and occupational therapy visits fee-for-service in the outpatient setting.

Procedure Codes Impacted:

97110 GP (Physical Therapy) and 97110 GO (Occupational Therapy)

Problem Begin Date:

July 2012

Problem Fix Date:

To be announced.  Continue to monitor this page for updates.

Resolution for Impacted Claims:

Claims that pay inappropriately as explained in problem #1 above must be voided by the provider. Resolution for claims rejecting in error is to be announced - continue to monitor this page for information.