Author Topic: BCBS out of state plan denying what's covered by our local BCBS. Help!  (Read 2604 times)

thatcuteblonde

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My doc has billed for an MUA (Manipulation Under Anesthesia) where we are located (IL). The patient's BCBS plan is through Alabama and has denied the services indicating they can't be done by a Chiropractor, however through Blue Cross of IL it is allowed and payable. He is licensed in the state of Illinois to render these services. Has anyone had any experiences like this or does anyone have any advice/suggestions on appealing this denial?

The patient had three of them prior to us receiving the denial, so there is a $15k bill! Any help will be greatly appreciated.

Pay_My_Claims

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Unfortunately, my experience won't help you in a way you need it. I have had several claims for BCBS for DME in which certain things are considered "non covered" by the clients policy, but are covered by our local BCBS. It would all be determined on the individuals plan.

Michele

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A little late to ask, but did you call to verify benefits on the patient's plan before the services were rendered?  If so, what were you advised? 

You can try to appeal by including information showing that the services are allowed and covered in IL, but I'm not sure if it will make a difference.  I would write up an appeal letter, include that info and try it.  It's obviously worth the effort.

Good luck

Michele
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PMRNC

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If the service is not covered in the underwriting state (Alabama) then it will not be covered.  Coverage is determined by the location of the plan and where it was written.
Linda Walker
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Pay_My_Claims

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If the service is not covered in the underwriting state (Alabama) then it will not be covered.  Coverage is determined by the location of the plan and where it was written.

FIRST rule of billing VERIFY VERIFY VERIFY

thatcuteblonde

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Believe you me, I hear you on the verifying. Unfortunately, I came into the scenario here a bit late and the 'office manager' i.e. glorified title given to a woman with basic clerical skills and no knowledge of billing, has been doing the verifications. I have run into numerous problems with the half, um, tail, way she has been doing so.

I found out the services are not excluded in the policy provisions however the codes for MUA are in the surgical section of the CPT book therefore as a chiro they are denying as outside the scope of this license, however here in IL he is licensed to do so. I called to verify benes afterwards and was told it wasn't listed as an exclusion and that we'll have to appeal, I was just curious as to the best method of presenting our case.

Michele

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Good luck with the appeal.

Michele
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midwifebiller

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I would have the member go to their HR department and complain.  If HR will advocate for the member and contact their BCBS plan, there is a much greater chance of an appeal being honored.

~Kelli
Kelli Sugihara, CPMB
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