February 6, 2012

Claims submitted to MO HealthNet may, due to the adjudication system requirements, have service lines separated from the original claim. This is commonly referred to as a split claim. Each portion of a claim that has been split is assigned a separate internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, a maximum of 28 service lines per claim are processed. All detail lines that exceed the size allowed are split into a separate claim. If a claim denies for more than 25 edits, the claim must be split into multiple claims.

Timely filing, duplicate claim submission, third party liability and spenddown all post an edit for each line and can cause a claim to deny for more edits than the system can process. Providers can avoid this type of claim denial by submitting smaller claims with fewer line details.

MO HealthNet applies editing to Medicare/MO HealthNet crossover claims very similar to that used to process MO HealthNet only claims. The system can only process 25 edits or less on one claim. If the claim denies for more than 25 edits, the crossover claim must be split into multiple claims. When splitting the claim into multiple claims, the claim header charge will be different than the one sent to Medicare because the claim header charge must reflect the total charge of the service lines on the smaller split claim.

Providers can also bill smaller claims to Medicare so that the claim can crossover correctly without being manually split to address more than 25 edits.

Additional information regarding split claims can be found in Section 17.6 of the provider manual. Information regarding Medicare/MO HealthNet crossover claims can be found in the Crossover Claim Editing Bulletin, Volume 29, Number 8 dated August 21, 2006.