Tricky Anthem CT psych visit question, 99213/90862

[James B]

We are a psychiatric office that is out-of-network with Anthem and we have a patient with a State Bluecare POE policy. Strangely, this policy has no OON mental health coverage but reimburses 100% for OON medical. In the past we have gotten paid on 90862 charges but any therapy codes were denied as OON.

In 2013, they are denying our 99213 charges. Any idea why they would have paid 90862(they must have considered it medical) in the past but now deny payment on 99213? We have a few patients with this same situation. Thanks in advance for any advice.

[rdmoore2003]

Have you called Anthem on any of these claims?

[PMRNC]

We are a psychiatric office that is out-of-network with Anthem and we have a patient with a State Bluecare POE policy. Strangely, this policy has no OON mental health coverage but reimburses 100% for OON medical. In the past we have gotten paid on 90862 charges but any therapy codes were denied as OON.

These are partial HMO's (many companies switched to these to cover alternative services, even chiropractic, but they never really caught on)  that won't be able to continue after the ACA. HOWEVER I'm not understanding their NOT covering the E/M if they covered the 90862 previously (Yes they probably covered it under major med) It could be that they are now restricting all coverage for diagnosis relating to mental health, have you been paid at all for 2013? What exactly did the Denial state?   Also if you are OON with BCBS they will not assign benefits to provider, so is it possible the charges were paid to the patient?