INSTITUTIONAL DUPLICATE LOGIC UPDATE
Date: 04/19/24
Recently, Meridian Medicaid Plan (Meridian) and YouthCare HealthChoice (YouthCare) updated the duplicate logic for institutional claims to better align with the guidance of Illinois Healthcare and Family Services (HFS). Duplication logic reviews the submitted fields for UB04/837I claims against historical paid claims to ensure appropriate billing in accordance with HFS guidelines.
Duplicate logic reviews the following fields.
- Member ID (RIN) (field 60)
- Billing NPI (field 56)
- Statement covers period: from—through (field 6)
- Type of bill (field 4)
- Taxonomy code (field 81)
If a submitted claim matches another claim that was previously paid, that match on the key fields above, the system will deny the claim as a duplicate. Please note this process will review claim header level fields only. No line level fields will be used to identify a current claim as unique. For example, all services provided in an outpatient setting (TOB 13X) must be billed on a single claim unless the facility billing is enrolled with a separate COS that allows separate billing.
Duplicate example—hospital submits two claims as highlighted below:
- Charges for a clinic visit (claim number 123)
- Charges for lab on the same date (claim number 124)
Claim number: 123
Member ID: 999999999
Billing NPI: 3333333333
Statement covers period: 7/27/2023 – 7/27/2023
Type of bill: 131
Taxonomy code: 282N0000X- general acute
Revenue code: 0510
Procedure code: G0463