Bundled or included in another service

What it means

Your plan decided that one charge on the claim is part of another service done at the same visit, so it did not pay it separately. Sometimes the plan is right. Sometimes the two services were separate and the claim did not show that. The bill that results can look like a denial but is often a coding question.

Your explanation of benefits (EOB) shows the amount the plan paid and the amount it did not. The wording may say “included in another service” or “not separately payable.”

Who has to act first

The provider’s billing office, with your prompting. It knows how the claim was coded and can send a corrected claim if the codes did not describe what was done. You start the process:

1. Call the billing office with your EOB. Ask which codes were billed, whether they describe two separate services, and whether it will review and resend.
2. Ask it to hold your account while it reviews; it is not required to, and an unpaid bill can go to collections, so ask before you withhold any payment.
3. If the office will not act, you can appeal yourself.

For a job-based plan or a non-grandfathered individual plan, you have at least 180 days after you receive the denial notice to file the first appeal; your plan may allow more. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. Check the date on your notice, which controls.

Arguments that work

• The services were separate. Operative or visit notes show two distinct services: a different problem, area or time. Only the provider’s records can show this.
• Check the codes. After a denial, a non-grandfathered plan must give you the diagnosis and treatment codes and their meanings on request. Asking is not an appeal.
• Ask what rule the plan used. If the plan relied on an internal rule, guideline or protocol, the notice must set it out or say a copy is free on request. Ask for its payment policy on bundled services.
• Fresh look on appeal. The appeal must be decided by someone other than the person who made the first decision, who gives no deference to it.
• Your records. You have a right to a provider’s billing records and your plan’s claims records under the privacy law known as the Health Insurance Portability and Accountability Act (HIPAA). The plan or provider must act within 30 days, with one possible 30-day extension if it explains the delay in writing.

Evidence to gather

• The EOB with the plan’s wording for the line in question (you).
• The itemized bill with the codes (the provider).
• Visit or operative notes (the provider).
• The diagnosis and treatment codes and their meanings (the plan, on request).
• The plan’s payment policy for the rule it used (the plan).

What to send

First send the billing office a short request to review the coding and resubmit, using the note to the doctor’s office or the reprocessing script. Keep a note of the date and the person. If the claim is corrected, the plan reprocesses it and issues a new EOB. If the provider will not change the claim, send the plan a written appeal with the visit notes showing the services were separate, using the coding error appeal letter.

When this is not worth an appeal

If the billing office confirms in writing that the two services really were one and the plan paid correctly, an appeal has little to change. Check that you are not billed for the bundled amount, and ask for a payment plan or a discount if you owe a share.