June 17, 2016
AlphaMCS Site Adjudication Edit in Effect July 1, 2016
If authorization site and claim site do not match, claim will deny
In Provider Communication Bulletin #40 (January 29, 2015), providers were asked to make sure that authorization sites and claim sites match. Partners has continued to pay providers for the claims, despite some of the authorization sites and claims sites not matching.
Effective July 1, 2016, an edit in AlphaMCS will adjudicate claims based upon the authorization site and claims site. If the sites do not match, the claim will deny.
The same will occur for Partners. If a provider’s authorization site and claim site do not match, then Partners will not be reimbursed for the service, and the provider will not be paid.
We strongly encourage all providers to make sure that:
the site billed on any current claim matches the site on the current authorization in the Partners system. Any claims billed with a site that is different from the site on the current authorization will deny.
all new authorization requests are requested for the site from which the service will be delivered. (Note–this is not the same as Place of Service). Claims should be billed with the same site requested and approved on the authorization.
If you have any questions related to service authorization site and claim sites, contact your Provider Account Specialist.
If you need more specific details regarding claims adjudication, please contact the Claims Department at email@example.com.