Wiki Skilled Nursing Facility Outpatient Therapy Billing for Anthem in Ohio

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rober187

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Per our therapy contract with Anthem they as that we bill for outpatient therapy on a 1500 with each therapy type on a separate claim. ie. OT would be its own claim, PT its own claim and SLP its own claim. So it is possible to have 3 claims for therapy during a particular date range. Anthem consistently does not pay the claims. they are denying for place of service (31) as well as not covered per managed care contract. Is anyone else experiencing this and if so what is the solution? It is extremely difficult to get in touch with someone at Anthem who is able to assist with the issue. Any billing insight or Anthem contacts will be quite helpful.
 
Isn't PT and OT required to be provided by the SNF? I bill for physician services at an inpatient rehab hospital, and I know they're required to provide those services to the patient - they cannot be billed separately. I thought POS 31 was the same as far as requirements go.
 
That's only if they're doing a skilled stay, then the therapy would be all-inclusive. However. outpatient therapy would be for those that may have transitioned to the long-term care side, and therapy is not included in the per diem rate.
 
Then wouldn't the POS be something other than SNF? Alot of SNFs have different POS for different types of stays. Wouldn't it be 31 for nursing facility or 13 for assisted living?

I think the problem is that POS 31 is required to provide the therapy.
 
something other than SNF like what? the contract is for the SNF facility not an individual provider. Additionally, the services are truly being rendered there and not an office.
 
Like I said... since it is not really skilled nursing facility services, then 31 would be incorrect. The likelihood is high that the codes you are using are not payable in POS 31. The patient is more likely in a POS 13 for assisted living or 32 for nursing facility (I said 31 for nursing earlier but i meant 32).

One facility can have more than one POS code.
 
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