Bundling Policy

Background

The May 2024 change to the Centers for Medicare and Medicaid Services (CMS) resubmission policy remains a point of confusion due to the many differing interpretations of which items or services are included for reimbursement in a bundled payment.

FHAS recently obtained clarification from CMS that will allow us to proceed with processing disputes.

The following policy and instructions should help clarify the matter.

Policy

FHAS requests that a statement be provided to us indicating which option best describes your billing practices. An authorized representative must designate one of the two bundling statements:

Statement 1

When [Issuer’s Name] has an allowed amount allocated to only one item or service, the allowed amount is only meant to be applied to that one item or service and should not be applied to other items and/or services listed on the claim.

Implications

This option would disallow any provider from submitting a single claim that contains only one item or service with an allowed amount greater than $0 to be disputed in the Federal IDR process as a bundled dispute for the entire claim amount.

This would require providers to submit multiple single disputes containing only one item or service for all item(s) and/or service(s) that the provider wishes to dispute. It would not disallow providers from submitting a single claim under the Federal IDR process as a batched dispute.

Statement 2

When [Issuer’s Name] has an allowed amount allocated to only one item or service, the allowed amount is meant to be applied to all item(s) and/or service(s), regardless of the EOB stating $0 allowed for any given item or service on the claim.

Implications

This option would allow any provider to submit a single claim that contains only one item or service with an allowed amount greater than $0 to be disputed in the Federal IDR process as a bundled dispute for the entire claim amount.

This would require providers to submit only one bundled dispute containing all items and/or services for all items and/or services on a single claim.

Important to note

CMS does not allow for an entity to add DLIs that were not included in the original submission.

Parties must file every CPT within the CMS portal that they hope to dispute. For example, if a 99285 is filed by itself (with the intention of arbitrating all codes that happened during the service) the arbitrator will treat the service as a single submission, without considering the subsequent services that occurred while within the emergency room.

Conclusion 

Statements can be emailed to IDRE@fhas.com with the Subject: “Bundling Policy Response.” Until a statement is received, FHAS, as directed by CMS, will process the dispute under the interpretation that the allowed amount is meant to be applied to all item(s) and/or service(s), regardless of the EOB stating $0 allowed for any given item or service on the claim.