Electronically Submitted Claims that Exceed $99,999.99 Reminder
Electronically submitted claims containing a dollar amount in excess of 99,999.99 will be rejected as a front-end EDI edit.
The Standard Companion Guide for Health Care Claim: Professional (837P) clarifies and specifies data content when exchanging transactions electronically with Medicare. The instructions given pertaining to the maximum number of characters submitted in any dollar amount field is seven characters. Therefore, claims that exceed this amount need to be submitted on separate claims as the following:
Scenario # 1: Billing One Line of Service
First Claim: Submit the service with an acceptable billed amount (< $99,999.99).
- In the documentation field, identify this as, "Claim 1 of 2; Dollar amount exceeds charge line amount."
Second Claim: Submit the service with CPT modifier 59. Enter the billed amount as the remaining dollar amount.
- In the documentation field, identify this as, "Claim 2 of 2; Remaining dollar amount from Claim 1 amount exceeds charge line amount."
For example, if the billed amount is $100,000.00, submit the billed amount on the first claim as $51,000.00; on the second claim submit the billed amount as $49,000.00.
Scenario # 2: Billing Multiple Lines of Service
First Claim: Split the lines of service with an acceptable billed amount(s) (< $99,999.99).
- In the documentation field, identify this as, "Claim 1 of 2; Dollar amount exceeds allowable claim amount."
Second Claim: Enter the remaining lines of service and remaining billed amount(s).
- In the documentation field, identify this as, "Claim 2 of 2; Remaining dollar amount from Claim 1 amount exceeds allowable claim amount."
For example, if the claim billed amount is $100,000.00, split the lines to ensure that each claim total is less than $99,999.99. After splitting the claim, if the first claim total is now $51,000 then the second claim would be submitted with the additional lines of service and the remaining billed amount of $49,000.00.
Keep in mind:
- If you do not note in the documentation field the reason the claim is split this way, it will be denied as a duplicate.
- When splitting the billed amount, be sure the dollar amounts are slightly different, as this will prevent the system from assuming the two claims are an exact duplicate.
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Posted 8/20/2024