APS has experienced claims processing issues for Anthem Ohio denying professional services, stating services paid to another provider/facility. After calls to Anthem’s claim department and Provider Relations Representatives, we’ve discovered that hospitals are billing their technical component on a CMS 1500 form without a TC modifier. With the modifier being absent from the claim, Anthem is processing and paying the hospital at a global rate. This issue has been experienced multiple times across various health systems over recent years.
Anthem Blue Cross and Blue Shield’s Commercial Professional Reimbursement Policy (0029), states that a TC or 26 modifier must be placed on the claim, otherwise the claim is considered global. The policy also states that when one provider reports a global charge and a different provider reports the same charge with a 26 or TC modifier, the first charge processed will be paid and the subsequent charge will be denied. The policy can be found here.
It is important to detect these denials early on, in order to educate hospitals on proper usage of modifiers. APS will continue to pinpoint, research, and resolve carrier issues such as this to ensure our providers are paid appropriately for the services they perform. If you have any further questions regarding this matter, please contact your Practice Manager.
In working through the wide variety of billing arrangements, APS found payments that we had been missing.