Interim bill edits
Smart Claims Engine for Healthcare allows interim billing edit for payment of inpatient and outpatient institutional services only when there are some more bills in the past for the same member and from the same billing provider with same admission date. Hospitals must bill each interim-billed claim as an adjustment to the previous interim-billed claim and must include the following:
- The date span between the admission date and the current date of service billed.
- All inpatient hospital services provided for the date span billed.
- All applicable diagnosis codes and procedure codes for the date span billed.
The Claim Engine Configuration screen provides you with the capability to create the logic used in the Interim billing based on the criteria listed above. Once the logic for editing is set within Smart Claims Engine for Healthcare, its corresponding event code is applied and the claim is routed to the appropriate workbasket for the event code.
The following tables describes the configuration logic against interim bill event code.
| Frequency Code | Claims |
| Frequency Code 2 | First Claim |
| Frequency Code 3 | Interim Claim |
| Frequency Code 4 | Last Claim |
Currently, Smart Claims Engine for Healthcare sets six types of pends for the Interim Bill claims edit.
The Frequency Code is the third digit of the type of bill (TOB3) submitted on an institutional claim record to indicate the sequence of a claim in the beneficiary's current episode of care.
| Pend Code | Pend code reason and description |
| Set Event code SBA-0001 | When frequency code 2 is on the claim and the history claim has the same admission date and billing provider. (The interim Bill Start claim is out of sequence). |
| Set Event code SBA-0002 | When frequency code 4 is on the claim and the history claim has the same admission date and billing provider. (The interim Bill claim is out of sequence). |
| Set Event code SBA-0003 | When frequency code 4 is on the claim and no interim 2 exists, where the history claim has the same admission date and billing provider. (The Interim Bill- Final Claim is Out of Sequence). |
Set Event code SBA-0004 | When frequency code 4 is on the claim and gaps on other interim claims, where, the history claim has the same admission date and billing provider. (The Service Dates of an Interim Bill are overlapping). |
| Set Event code SBA-0005 | When frequency code (for example, 2, 3, or 4) is present and no admission date exists, where the history claim has same admission date and billing provider. (Interim Bill requires Admission Date). |
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