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Meridian Medicaid Plan and YouthCare Institutional Duplicate Logic Update with Examples

Date: 06/27/25

Meridian Medicaid and YouthCare plans previously updated the duplicate logic for Institutional claims to better align with the guidance of Illinois Healthcare and Family Services (HFS). Please find examples below to help guide claims submissions.

Duplication logic reviews the submitted fields for UB04/837I claims against historical paid claims to ensure appropriate billing in accordance with HFS guidelines.

Meridian duplicate logic reviews the following fields.

  • Member ID (RIN) (Field 60)
  • Billing NPI (Field 56)
  • Statement Covers Period – From – Through (Field 6)
  • Type of Bill (Field 4)
  • Taxonomy Code (Field 81)

If a submitted claim matches another claim that was previously paid that matches the key fields above, the system will deny the claim as a duplicate. Please note this edit will review claim header level fields only. No line level fields will be used to identify the current claim as unique.

For example, all services provided in an Outpatient setting (TOB 13X) must be billed on a single claim unless the facility billing is enrolled with a separate COS that allows separate billing.

Duplicate Example: Hospital submits two claims as illustrated below.

  • Charges for a clinic visit (Claim Number 123)
  • Charges for lab on the same date (Claim Number 124)

Claim Number: 123
Member ID: 999999999
Billing NPI: 3333333333
Statement Covers Period: 7/27/2023 – 7/27/2023
Type of Bill: 131
Taxonomy Code: 282N0000X- General Acute
Revenue Code: 0510
Procedure Code: G0463

claim example

Claim Number: 124
Member ID: 999999999
Billing NPI: 3333333333
Statement Covers Period: 7/27/2023 – 7/27/2023
Type of Bill: 131
Taxonomy Code: 282N0000X- General Acute
Revenue Code: 0300
Procedure Code: 36415

claim example

The system will deny Claim 124 as a duplicate because the Member ID, Billing NPI, Type of Bill and the Taxonomy code all match along with the Statement Coders Period overlaps and are for the same HFS Category of Service (024) for general acute outpatient services.

The expectation is that the two claims would be submitted as one single claim to avoid a duplicate denial that includes the 300-revenue code and 0510 revenue code lines and the corresponding procedure codes.

Non-Duplicate Example: A hospital submits two separate claims as illustrated below.

  • Charges for a service on the dialysis unit (Claim Number 125)
  • Charges for Outpatient Psych Clinic B Services on the same date (Claim Number 126)

The system would not deny Claim Number 125 (Dialysis- HFS Category of Service (COS) 025) as a duplicate because Claim Number 126 is for a separate Taxonomy code and HFS Category of Service (HFS COS 028) that makes each claim unique and must be billed separately by HFS category of service (COS 025 Vs COS 028).

Claim Number: 125
Member ID: 999999998
Billing NPI: 3333333333
Statement Covers Period: 10/30/2023 – 10/30/2023
Type of Bill: 131
Taxonomy Code: 261QE0700X - Dialysis
Revenue Codes: Several related to the services rendered on the dialysis unit including 0821

claim example

Claim Number: 126
Member ID: 999999999
Billing NPI: 3333333333
Statement Covers Period: 10/30/2023 – 10/30/2023
Type of Bill: 131
Taxonomy Code: 273R00000X – Psychiatric Unit
Revenue Code: 0912
Procedure Code: S9480

claim example