Billing for services reported on split claims

Effective May 1, 2018, Priority Health will require that all services provided on the same date of service by the same provider be reported on a single claim billed on a CMS-1500 or electronic 837 transaction.

Failure to report all services on a single claim may result in inaccurate payments due to the inability to apply multiple procedure reduction, clinical edit criteria, claims adjudication criteria (ie. denials associated with duplicate logic, modifier use, CPT or HCPCS pairing). Services reported on split claim forms may result in an underpayments, overpayments, or claim denials.

Examples of split claim form billing

  • Reporting one procedure code on three different claim forms when performed during the same surgical session by the same physician
  • Reporting an E&M and procedure on two separate claim forms when performed during the same office visit by the same physician

Multiple claims will generate denials

Multiple services reported by the same provider for the same date of service will be denied or adjusted to deny if we receive multiple claims. You will then need to submit all services on a single corrected claim for reimbursement consideration. 

Correcting claims

If we identify that a service was omitted from the original claim submission, you'll need to submit a corrected claim containing all services for the specified date of service. Instructions for submitting a corrected claim can be found in the Provider Center under Billing and payment > Correcting claims.