Author Topic: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!  (Read 1663 times)

sakurasanta86

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Good morning! Hoping I can get assistance with what my next steps should be.

We have a patient we have done the same procedures on 8 times since November.

Before we ever did the procedure, I called multiple times to check to see if authorization was needed. I was told the same thing every time which was all codes are valid and billable no precert required. Two of the codes are covered if medically necessary, notes may be requested to pay claims.

At first, denials were coming in asking for ops notes. They were submitted.

They are Outpatient SX claims. The facility claims are the biggest issue. They are being denied as not covered. but then below that it says, "we have found the service requested is not medically necessary in your case". It then goes on to say "based on current information, coverage cannot be approved because there is insufficient scientific evidence to demonstrate the  safety and/or effectiveness of Amnioband for any indication including wound care....Falls under experimental/investigational/unproven, which the customers plan does not cover."

I need advice on what I can do next. (Appeal, have the doctor discuss with a physician reviewer, send claims to a service like Collect RX). This is a first and I'm confused as to how so many CSRs including the preauth department that these codes were covered and do not require precert and then be denied as not covered. Can someone please help me understand? Thank you in advance and if more information is needed, I will do my best.


kristin

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In order to assist you better, it would be helpful to have more info, specifically what the patient's insurance is, and what codes were billed, and if you are billing for the provider side, or the facility side. I have a feeling I know what is going on already, since these appear to be graft claims, and those can be very problematic. One piece of advice I can give right away is to contact MTF Biologics who manufactures Amnioband, and talk to your representative there, or their billing/coding team. Every graft manufacturer I have ever dealt with has a specific person/people to talk to when dealing with denials concerning their products.

Michele

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I would try what Kristin suggested.  The only thing I would add is that if the dr disagrees (which I assume they do) then I would definitely appeal.  I would have the dr do a written explanation as to why they disagree and why they feel the procedures were medically necessary and include any supporting documentation.  It is crucial that the dr is VERY specific and detailed in why they disagree and why it was medically necessary.  Include absolutely any documentation possible to support the drs opinion. 
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PippiT

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #3 on: October 02, 2018, 02:27:12 PM »
Strange, this post is word for word my post from last year.  ;D

Michele

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #4 on: October 03, 2018, 10:34:51 AM »
Wow, it took me some digging but PippiT you are right!  You posted this post in February 2017.  Wonder why they would repost your old question.  There appears to be no spam but it's such a specific question it can't possibly apply to any one else.   ???
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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #4 on: October 03, 2018, 10:34:51 AM »

PippiT

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #5 on: October 17, 2018, 04:37:59 PM »
Wow, it took me some digging but PippiT you are right!  You posted this post in February 2017.  Wonder why they would repost your old question.  There appears to be no spam but it's such a specific question it can't possibly apply to any one else.   ???

LOL. So strange!

Medical Billing Forum

Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #5 on: October 17, 2018, 04:37:59 PM »