Beginning on April 1, 2019, Mercy Care will be collaborating with Equian, to ensure consistency in claims review and reimbursement practices with our hospital partners by reviewing all facility claims that exceed outlier thresholds.
Mercy Care will continue to require submission of itemized bills for all DRG facility claims with a billed amount of $65,000 and higher, and all Critical Access Hospital (CAH) facility claims with a billed amount of $5,000 and higher. You must submit an itemized detail listing each supply and service provided to the patient and match the billed charge amount for the underlying claim for submission of all Inpatient facility outlier claims.
Itemized Bill Requirements:
- The itemized bill must list each supply and service provided to the member and match the dollar amount and date of service of the request.
- The request will apply to claims submitted with other insurance, changes in coverage, lapse in coverage or if the member’s coverage termed during the length of stay.
- Interim billing will not require an itemized bill; however, it will be requested once the final bill has been submitted.
- The itemized can be submitted via paper and electronically through our web portal.
What happens if the claim does not meet the requirements?
If the itemized bill is not included with the claim, the claim will not be considered for Outlier payment; if payable, the claim will be priced at the DRG rate only. For outlier consideration a new claim will need to be resubmitted with the itemized bill. To avoid a duplicate denial, please resubmit as a corrected claim.
How will Company communicate its findings?
If Equian identifies any billing issues during its pre-payment review, they will send you detailed findings regarding these issues and provide you with a direct contact with whom you can discuss and resolve any issues you may have with its findings. You can also exercise your right to request reconsideration of Equian’s findings.
Please send all reconsideration correspondence by mail or email directly to Equian at:
Attn: Reconsideration Department
600 12th Street, Suite 300
Golden, CO 80401
While every attempt should be made to resolve any disagreements with findings directly with Equian during the pre-payment review, providers still maintain their rights to file a claims dispute directly with Mercy Care. Claims Disputes must be sent to:
Attn: Appeals Department
4755 S 44th Place
Phoenix, AZ 85040
As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our
Mercy Care website
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