Medical Billing Forum

General Category => General Questions => Topic started by: debfini on June 01, 2015, 04:24:06 PM

Title: Received deial for BCBS claim where Medicare is primary and provider is LPC
Post by: debfini on June 01, 2015, 04:24:06 PM
Dear Lord,

I absolutely know that we have talked about this issue till we are "blue in the face"......however, I bill for an LPC in Virginia.  She now has (2) clients where Medicare is primary and secondary is BCBS.  I have been billing one client using the GY modifier (fingers crossed) for about 1 1/2 years and BCBS pay!!!  Now have a new client with same scenario and sent the claim with GY modifier - DENIED "Status: Finalized/Denial The Claim/Line has been denied.
Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services). Status Date: 05/19/2015".....

I love this group and the different solutions you can find on this forum!!  However, is there ONE rule to follow?  I really am at my wits end of having this issue come up for the last 20 years.  I have handled so many different ways to just get the claim paid.  Does anyone have the one solution to this never ending problem, please help!!!

Thank you for taking time to read this - I really would appreciate more guidance on this issue.

Debbie

Debbie Gilbert
Ashburn, VA
703-729-6320
Title: Re: Received deial for BCBS claim where Medicare is primary and provider is LPC
Post by: PMRNC on June 01, 2015, 06:09:51 PM
Debbie, while it might seem these are same scenario's.. they might be different secondary plans. What is the COB method of the secondary plan you are having trouble with. That makes a big difference. When benefits are verified on a patient with a secondary, you must ask the secondary what method of COB they utilize.
Since primary is Medicare, there's a good chance it could be a "carve out" to which the secondary will not pay anymore than their liability had they been primary.

So no .. there is NO one rule with COB. The secondary plan will determine what COB provision that plan utilizes.
Title: Re: Received deial for BCBS claim where Medicare is primary and provider is LPC
Post by: debfini on June 03, 2015, 12:03:42 PM
Linda,

Thank you - you always, always make so much sense.....got it!!!

Thank you,

Debbie
Title: Re: Received deial for BCBS claim where Medicare is primary and provider is LPC
Post by: Billing2 on July 21, 2015, 08:52:08 PM
We just had them same issue with a BCBS. I was told I need a letter from Medicare stating that they do not cover LPC.
Once we got that then BCBS started paying.