Top 10 Outpatient Billing Errors

Below are the top ten outpatient billing errors that may result in delayed payment or no payment for submitted claims. If you have any questions please feel free to call the Health Care Compliance Officer, Angela Caruso at 545-8993.

1. Duplicates: Claims submitted are exact duplicates of previous claims submitted.

2. Bundled Services: Payment for services is always bundled into payment for other services.

3. Facility Information: The name and address of the facility for Item 32 is required.

4. Beneficiary Eligibility: Claims submitted for processing when the patient does not have Medicare eligibility. This includes: beneficiary Medicare number is invalid on the claim; beneficiary is not eligible to receive Medicare benefits; or beneficiary’s claims must be filed to another insurance plan.

5. Medical Necessity: Services billed and deemed not medically necessary by the payer.

6. Provider Identification Number Missing:

   • No individual PIN in Item 24k

   • No group PIN in Item 33

   • Individual PIN and Group PIN listed in Item 33

   • No PIN number submitted

7. Medicare Secondary Payer: The care of a Medicare patient may be covered by another payer through coordination of benefits.

8. Non-Covered Services: Billing for services not covered by Medicare.

9. Unique Provider Identification Number (UPIN): The UPIN number and physician name is required information when a claim involves referring and/ or ordering physician services.

10. Modifiers: Missing/ incomplete/ invalid/ incorrect for the service.

Compiled by The Trailblazer Health Enterprises, a Medicare fiscal intermediary.