OBH Facets Duplicate Claim Handling
| Original Effective Date | 12/28/2009 |
|---|---|
| Revision Date | 01/09/2026 |
Overview
Purpose
This document provides essential guidelines for handling duplicate claims. Follow any plan specifics.
DUPS Warning Message
DUPS – Possible Duplicate Claims On File For This Member appears on:
- Related claims — profee + hospital possible duplicates; different providers same TIN.
- Similar claims — same Provider/CPT/DOS different charge; fields off but mostly same.
- Denied claims — same claim, original denied, zero allowed.
Medicaid Reclamation → Medicaid Reclamation P&P. ECT/Anesthesia → OBH Facets ECT Treatment P&P.
Claim Cross Billing
Refer to Cross-Billing Prevailing Code List for allow/deny codes. Same Provider (name/TIN/credentials), same patient, same DOS.
Note: Does not apply to Virgin Island Providers (see TIN list below).
| If code is to… | Then… |
|---|---|
| Allow | Process per normal guidelines. |
| Deny | Deny with override; same provider use (W46/W47) for services included in primary proc. |
Virgin Island Providers excluded (TIN / Provider Name)
| TIN | Provider Name |
|---|---|
| 228883468 | ETHERIDGE, WAYNE C |
| 239159611 | CATHERINE GIRALDI |
| 550814917 | MCCORMICK, LAURIE MAY |
| 577692969 | EVADNE SANG |
| 580057972 | LEIGHMIN LU |
| 580068086 | JEWEL OWEN, PSYD |
| 580098584 | DUDLEY-GRANT, RITA |
| 580231263 | DARA HAMILTON |
| 583626996 | GLORIA MENDEZ |
| 579549383 | DEREK V SPENCER, MD |
| 660545955 | MOSS, RAMONA J |
| 660586667 | FREDERIKSTED HEALTH CARE |
| 660637750 | ILIAS NIGAMATOV |
| 660695059 | INSIGHT PSYCHOLOGICAL SERVICES LLC |
| 660706342 | DR MARSHALLS CONSULTING SERVICES |
| 660738097 | LINDSY WAGNER LLC |
| 660779479 | MIND BODY HEALTH & PSYCHOLOGY LLC |
| 660798554 | LINDSY YARGER WAGNER |
Additional VI TIN rows may exist in PDF — verify against source if needed.
Duplicate Exceptions
- Providence: Exclude Physician Fee tips when facility TOB 085/013 + REV 510, 513, 521, or 900 and prof POS 22/19 same DOS.
- Oscar Mt Sinai TIN 131824096, 132997301, 135564934 — facility REV 513 + prof POS 22/19 same DOS.
- Seattle Children's (Commercial) TIN 910564748 — facility REV 510 + prof POS 22/19.
- Maryland Commercial/Medicare TINs 520608307, 520646893, 520591684, 520591685, 520607949, 520491660, 520591607, 521532556, 460726333 — facility REV 510 + prof POS 22/19.
- Harborview, UW Medical Center, NW Hospital — REV 0914/0915/0916/0513 + prof POS 22/19 (effective 09/01/2019).
- Monthly / daily / 15-minute case service rules; different physician not duplicate.
- Refer OBH Facets Warning Message Resolution for 0015 / DUP message.
Refer to Cross-Billing Prevailing Code List for modifier/payable instances.
| If… | Then… |
|---|---|
| Billing POS inpatient | More than one profee per day (not same CPT); do not follow cross-billing; next step. |
| Add-on codes | Do not follow cross-billing; next step. |
| H, S, T code | Do not follow cross-billing; next step. |
Duplicate Claim Review
Follow Step/Action; frequency maximums configured; autism → OBH Facets Autism Claims.
| 1 | Corrected or void claim (freq 7/8 in DOC360)? |
|---|
| If… | Then… |
|---|---|
| Yes | Not duplicate — refer to OBH Facets Claim Attachment Validation. |
| No | Next step. |
| 2 | Match NPI/TIN, Member, DOS, Procedure (excl. modifiers)? |
|---|
| If… | Then… |
|---|---|
| All match | Skip to Step 4. |
| Any do not match | Next step. |
| If… | And… | Then… |
|---|---|---|
| On Cross-Billing prevailing list | Same provider | Deny/Pay per grid; allow → normal; deny → W47 line or W48 claim; history paid in error → pend FB to ADJ. Proceed Step 9. |
| No results | — | Bypass duplicate; allow both CPT; Skip Step 8. |
| 4 | Determine status of claim in history. |
|---|
| If status… | Then… |
|---|---|
| 11 or 15 | Process current and history per policy; next step. |
| 02 | Next step. |
| 5 | Did claim(s) in history pay (paid amount > $0)? |
|---|
| If… | Then… |
|---|---|
| Yes | Next step. |
| No | Override Bypass Duplicate Edit EX Code 020; proceed Step 9. |
| 6 | Medicaid claim? |
|---|
| If… | Then… |
|---|---|
| Yes | Skip Step 8. |
| No | Next step. |
| 7 | Find current claim situation → proceed Step 9. |
|---|
All data must match to be duplicate: provider name/TIN/NPI, procedure + modifiers, DOS, POS, billed amount, units, DX (confirm on images).
| If… | And… | Then… |
|---|---|---|
| Denying duplicate (e.g. CDD) | — | Allow CDD deny; if not denying, override E51/F51. |
| Duplicate (same service code…) | Affiliated providers (diff name, same Tax ID) | Deny duplicate: EX 003 + E51 line; F51 claim. |
| Different provider names/TINs | Not affiliated | Claim override deny FS1; or not duplicate — Bypass EX D20/B01. |
| Medicaid Reclamation, different TAX ID | — | Deny duplicate: 003 + ES1 line; FS1 claim. |
| Additional/changed billed or allowed amount | — | Deny duplicate: 003 + ES1; FS1 claim. |
| Different POS — Telehealth both POS 02/10 | — | Deny duplicate (zero allowable 003 + line denial). |
| Telehealth + other POS same day | — | Bypass duplicate EX 020/001. |
| Office visit on both claims | — | Deny as duplicate. |
| Additional/changed units — Case Management | — | Not duplicate — Bypass EX 020. |
| New/changed modifier | — | Not duplicate — Bypass EX 020/e01; next step. |
| Corrected EOB | — | Note "Possible adjustment" + original claim #; pend (F5) to ADJ. |
| Physician claim; profee paid under Hospital Application | TINs match | Deny all lines F24 — Previously paid same FED ID. |
| Physician claim; profee paid under Hospital Application | TINs do not match | 003 + E51 line; F51 claim — Duplicate after review. |
| Professional claim POS 22/19 | Facility in history per Duplicate Exceptions | Bypass duplicate; allow prof separate from facility. |
| Physician fee on UB; history paid physician | — | Deny facility profee F55 — Chgs incl. pro component. |
| Denying duplicate CDD | — | Allow CDD-Definite Duplicate; proceed next step. |
| Additional/changed amount, no other changes | — | Deny: 003 + E51 line; F51 claim. |
| Corrected EOB attached | — | Note + pend (FS) to ADJ. |
| Telehealth POS 02/10 or mod 95/GT | Both telehealth | Deny as duplicate per telehealth rules. |
| Affiliated — diff name, same Tax ID | Office + Telehealth same day | Bypass duplicate; allow payment. |
| Not affiliated — same name, diff Tax ID | — | Not duplicate — Bypass EX 020/b01. |
| 8 | Medicaid claim situation table — check Claims Inquiry; verify modifiers. |
|---|
| 9+ | Complete processing per policy; press (F3) process, (F4) save when directed. |
|---|
If pend required: <Shift + F5> or File > Save > Pend/Continue.
Code Descriptions and Terminology
| Code Descriptions | EOB Codes List · Medicare Reason Codes · UM Service Group Code Glossary |
|---|---|
| Terminology | Optum Glossary of Terms, Abbreviations and Acronyms |
Revision History
Revision rows not fully legible in video end frames.
Business Details
| Platforms | Facets |
|---|---|
| Audience(s) | Auditor · Processor · Adjuster |
| State/DIV(s) | All |
| LOB(s) | Commercial |
| Product(s) | OBH |
| Documentation Contact | Knowledge Management Request Form |