High-dollar claims and split billing requirements
When submitting high-dollar claims for your Geisinger Gold (Medicare Advantage) patients, follow billing guidelines to help keep processing accurate and prevent unnecessary rejections or denials.
High-dollar claim submission limits
The CMS claims processing system enforces a limit on the total dollar amount that can be submitted on a single claim. For 837P (Part B electronic) transactions, dollar amount fields are limited to 7 characters, resulting in a maximum claim value of $99,999.99.
When claim amounts exceed this threshold:
- Claims must be split into 2 or more submissions
- Use modifier 76 (repeat procedure or service) on each subsequent claim
- Notate in the narrative why the claim is split. Each claim should have a different total dollar amount to avoid duplicate claim denials
Claims submitted without these required elements will be rejected or denied. This is particularly important for high-cost services such as drugs, hemophilia clotting factors and skin substitutes, where exceeding the maximum dollar threshold is common.
To ensure proper processing of split claims:
- Submit the service with an acceptable dollar amount (less than $99,999.99) on each claim separately
- Apply modifier 76 only to the subsequent claim(s)
- Clearly identify in the narrative that: “Claim 1 of X, dollar amount exceeds charge line amount.” Transmit your narrative details in item 19 of the CMS 1500 claim form or in loop 2400 (line note), segment NTE02 (NTE01=ADD) for electronic claims. For subsequent claims narratives, include the following detail: “Claim 2 of X, remaining dollar amount, amount exceeds charge line amount.”
- An appropriate administration code can be billed on the first or second claim, not both, for drug billing.
Have a question about your claims?
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