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ADF - Corresponding procedure invalid, omitted or paid at zero

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Background:

ADF rejections are received on special visit premiums (SVPs). SVPs are only eligible for payment with certain parent service codes, and pursuant to the rules set out in the Schedule. If a valid parent service is not billed with an SVP, or if a valid parent service is billed but not eligible for payment, the claim may be rejected.

Solution:

You will need to ensure there is a valid parent service (assessment/consultation) billed in the claim. For example, if you bill:

  • A775A (Comprehensive Geriatric Consultation)
  • K961A (Travel Premium – weekday, sacrifice office hours)
  • K992A (First Person Seen Premium - weekday, sacrifice office hours)

The claim will be rejected with ADF, as the SVP’s are not eligible for payment with the A775A code, as A775A requires the service date be scheduled in advance – thus eliminating the eligibility of the SVP’s (SVP’s are not eligible for billing with services scheduled in advance).

Another example, if you bill:

  • G325A (Haemodialysis – medical component alone)
  • K991A (Additional Person Seen – Weekday/daytime)

The claim will be rejected as the G325A is not an eligible “parent” code for the SVP to be eligible for payment (“Special visit premiums are only eligible for payment when rendered with certain services listed under Consultations and Visits and Diagnostic and Therapeutic Procedures – as per section GP44 of the Schedule of Benefits).

If a valid parent service was billed but the claim was rejected, it is possible the special visit premium is not eligible for payment based on the claim information, and in accordance with the Schedule. -> Ensure all claim details are correct, and if so, you will need to remove the ineligible premiums and submit the claim. For example, if you bill the following for a patient admitted in the morning and seen again later in the day:

  • A135A (Internal Medicine Consultation)
  • E082A (MRP Admission Premium)
  • K995A (Additional Person Seen – Monday to Friday, 17:00-24:00)
  • C132A (Internal Medicine – Subsequent visit)

Although a valid parent code (A135A) has been billed with the SVP, it is possible the claim will be rejected for the C132A having been billed on the same date. As SVP’s are not eligible for patients seen during rounds, the presence of the C132A can cause the SVP to become ineligible. You would need to remove the premium or the subsequent visit and resubmit the claim. Otherwise, your claim would need to be marked for manual review, and supporting documentation should be provided to your assessor for consideration.

*In some cases, the claim may not be rejected if SVPs are not eligible for payment, rather the code will be returned on an R/A without payment.

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