RFP S-44300-00010245 AttL OSPHL Billing Rules.xlsx
XLSX spreadsheet 16 KB Posted
- Attached to
- RFP for Laboratory and Collection Services
- Solicitation number
- S-44300-00010245
- Issued by
- Marion County, Oregon
About this file
This document is an Excel spreadsheet (Attachment L) detailing billing rules for the Oregon State Public Health Laboratory (OSPHL) under RFP S-44300-00010245, which comprehensively outlines complex billing and coding procedures for laboratory tests. The billing rules cover multiple scenario-based billing instructions for various medical tests, with a particular focus on specific CPT codes, insurance verification, Medicaid coverage, and specialized billing categories for different test types.
The billing rules include intricate guidelines for handling insurance claims, including scenarios for Medicaid coverage, self-pay patients, and special circumstances such as STD grant program coverage. The document provides 32 distinct billing rules that address different billing scenarios, including provisions for no-charge situations (such as unsatisfactory specimens or tests associated with studies or outbreaks), specific handling of Chlamydia screening tests based on patient age and insurance status, and multiple charging categories (A, B, C, and D) depending on the billable entity and test type. The rules are designed to ensure accurate billing, proper insurance verification, and appropriate handling of various medical testing scenarios for the Oregon State Laboratory.
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Sheet1
| Oregon State Laboratory |
| RFP S-44300-00010245 Attachment L - Example OSPHL Billing Rules |
Order Order Choice/Test Description Rule Additional Comments Status Code
| Grouping: Verify Medicaid Coverage, if applicable. | ||||
| 1 | CPT 87389; 87801; 86780; 86592; 86708; 86709; 86704; 86705; 86706; 87340; 87341; 86803; 86480; 87149; 87561; 87556; 87015; 87116; 86701; 86702 | Bill to submitting organization | If insurance is "Ccare" or if insurer denies claim completely - then bill to submittin organization | |
| 2 | CPT 87389; 87801; 86780; 86592; 86708; 86709; 86704; 86705; 86706; 87340; 87341; 86803; 86480; 87149; 87561; 87556; 87015; 87116; 86701; 86702 | Check for Medicaid coverage | If insurance is "No insurance," "Self-Pay," "N/A," blank, or insurance code is CONF0001, then check for Medicaid coverage | |
| 3 | CPT 87389; 87801; 86780; 86592; 86708; 86709; 86704; 86705; 86706; 87340; 87341; 86803; 86480; 87149; 87561; 87556; 87015; 87116; 86701; 86702 | Result of Medicaid Check - Medicaid coverage located | If billable, bill claim to Medicaid or CCO plan. | |
| 4 | CPT 87389; 87801; 86780; 86592; 86708; 86709; 86704; 86705; 86706; 87340; 87341; 86803; 86480; 87149; 87561; 87556; 87015; 87116; 86701; 86702 | Result of Medicaid Check - No Medicaid coverage | If billable, bill to submitting organization. | Bill claim to submitter, add status code |
| Grouping: Bill Submitter/Client | |||
| 5 | All Tests not listed above | Bill to submitting organization | If billable and insurance is "No Insurance", "CCare", "Self-Pay", "N/A" or blank, or if insurer denies claim completely then bill to submitting organization |
| 6 | All Tests not listed above | Bill Submitter ONLY | If insurance code is CONF0001 , then bill to the submitter only and add a status code of CONF. |
| 7 | All Tests not listed above | Bill to submitting organization | If insurance is "Ccare" or if insurer denies claim completely - then bill to submitting organization |
| 8 | ALL Tests | Apply Billing Category | If present on established location table |
| Grouping: Apply Unique Scenarios | ||||||
| 9 | ALL Tests | No Charge when no testing has been performed. | If "Result" column contains "Unsatisfactory" OR "Test not Performed", then no bill and assign status code "NOTEST" | Do Not Bill - Add Status Code to provide report later. | NOTEST | |
| 10 | Specimen = Bordetella pertussis/parapertussis Culture OR | |||||
| Bordetella pertussis/parapertussis/holmesii PCR | No bill Tri-county residents (Mult, Wash, Clack) | If county of residence = Multnomah, Washington or Clackamas, then no bill and assign status code of "CNTY" | Do Not Bill - Add Status Code to provide report later. | CNTY | ||
| 11 | ALL Tests | No Charge for Tests with Study IDs | If three or more characters are populated in "Study ID" field, then apply billing status code of "STUDY" and make not billable. | Do Not Bill - Add Status Code to provide report later. | STUDY | |
| 12 | ALL Tests | No Charge for Tests with Outbreak Numbers | If three or more characters are populated in "Outbreak Number" field, then apply billing status code of "OUTBK" and make not billable. | Do Not Bill - Add Status Code to provide report later. | OUTBK | |
| 13 | ALL Tests | ICD-10 Codes | If diagnosis code is blank, then populate with "NODX", bill submitter and assign status code "NODIAG" | Do Not Bill - Add Status Code to provide report later. | NODIAG |
| Grouping: Verify STD Grant Program Coverage | |||||
| 14 | Chlamydia Screen Final | STD Grant | STDI0001, < age 25, Chlamydia Screen Final - Bill to STD Grant | Do Not Bill - Add Status Code to provide report later. | STDG |
| 15 | IPP Patient for CT/GC | STD Grant | Any insurance (except CCARE), < age 25, Chlamydia Screen Final, IPP YES - Bill to STD Grant | Do Not Bill - Add Status Code to provide report later. | STDG |
| 16 | Chlamydia Screen Final | STD Grant | Any insurance (except CCARE, STDI0001), < age 25, Chlamydia Screen Final - Bill to Insurance or Submitter | Do Not Bill - Add Status Code to provide report later. | CTGC9 |
| 17 | Chlamydia Screen Final | STD Grant | STDI0001, >= age 25, Chlamydia Screen Final - Bill to Insurance if insurance is present or Submitter if no insurance is present | Add Status Code | CTGC1 |
| 18 | Chlamydia Screen Final | STD Grant | Any Insurance, >= age 25, Chlamydia Screen Final - Bill to Insurance if insurance is present or Submitter is no insurance is present | Add Status Code | CTGC3 |
| 19 | IPP Patient for CT/GC | STD Grant | Any Insurance, >= age 25, IPP YES - Bill to Insurance if insurance is present or Submitter if no insurance is present | Add Status Code | CTGC4 |
| 20 | Chlamydia Screen Final | STD Grant | If any Insurance, any sex, any age, IPP YES - Bill to Insurance if insurance is present or Submitter if no insurance is present | Caught under Rules, 23, 24, 25, & 26 | |
| 21 | IPP Patient for CT/GC | STD Grant | If any Insurance, any sex, any age, IPP NO - Bill to Insurance if insurance is present or Submitter if no insurance is present | Add Status Code | CTGC7 |
| 22 | Chlamydia Screen Final | STD Grant | CCAR0001, < age 25, Chlamydia Screen Final - Bill to Submitter | Add Status Code | CCARE |
| 23 | IPP Patient for CT/GC | STD Grant | CCAR0001, < age 25, IPP YES - Bill to Submitter | Add Status Code | CCARE |
| Grouping: Apply Final Status | ||||
| 24 | ALL Tests | Apply Category A Charges | If Billable to Insurance | See Charge Master |
| 25 | ALL Tests | Apply Category B Charges | If Billable to submitter and Category B | See Charge Master |
| 26 | ALL Tests | Apply Category C Charges | If Billable to Submitter and Category C | See Charge Master |
| 27 | ALL Tests | Apply Category D Charges | If Billable to Submitter and Category D | See Charge Master |
| 29 | ALL Tests | Apply STD Grant Charges | If STD Grant | Reporting Purposes |
| 30 | ALL Tests | Apply Unbillable Charges | If Unbillable | Reporting Purposes |
| 31 | ALL Tests | Apply Special Charges | If special charge exists for location | See Location Category List |
| 32 | ALL Tests | Revert Claim Status | If billed to insurance and denied for non-coverage or similar reason, revert charge to original status. | If grant covered, add to report; If billable to submitter, add to invoice. |
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