QUEST Integration – Hospital Interim Claims – Acute

Original Effective Date:

08/01/1994

Current Effective Date:

07/01/2022

Acute hospitals may submit interim claims when a confinement’s length of stay exceeds 30 days from admission, and every 30 days thereafter for QUEST Integration.

Claim Coding Requirements

• Use type of bill “112” to identify the first interim claim. It should include all services for the first 30 days from the admission date.
• Use type of bill “117” to identify any subsequent interim claims. Subsequent interim claims can be submitted every 30 days and should be a replacement of the first interim claim to include all services from admission through the next 30 days.
• The patient’s status in Form Locator #17 must indicate that the patient is still confined at the facility on all interim claims. Use appropriate discharge status on final claim once the member has been discharged. Discrepancies in this area will cause payment delays.
• Interim claims submitted with type of bill 113 or 114 are not payable. If billed, they will be denied as “NO PAYMENT CAN BE MADE. INTERIM BILL TYPE 113/114 ARE NOT ACCEPTED. PLEASE RESUBMIT WITH THE APPROPRIATE BILL TYPE, IF APPLICABLE.”

Payments

Beginning with admission dates on July 1, 2022, inpatient hospital services delivered through fee for service and managed care will be paid using the All Patient Refined Diagnosis Related Groups (APR-DRGs) payment methodology. Refer to the All Patient Refined Diagnosis Related Groups (APR-DRG) Overview (hmsa.com) article for more information.

Coordination of Benefits

When a primary insurer, such as a no-fault carrier, makes a lump sum payment for the entire confinement, you may apply the payment to the initial claim. If the lump sum payment is greater than the initial claim charges, apply the balance of the payment to the subsequent interim claim(s).

If the entire payment was applied to the initial claim, subsequent claims should continue to list the primary payer with $0.00 in the Form Locator #54 “Prior Payments” field. In the Form Locator #80 “Remarks” field, indicate that the entire medical benefit was applied to the first claim, and attach copies of any applicable documentation, such as the no-fault benefits exhausted letter.

Revision History