Author Topic: Need help billing E0486  (Read 1646 times)


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Need help billing E0486
« on: November 04, 2016, 07:39:50 AM »
I am new to billing medical insurance as we are a dental office that has just started making oral appliances for sleep apnea.  I am trying to let the patient know how much she has to pay.  I have submitted a pre-auth to her insurance company.  We are out of network and I was told she has met her deductibles and they pay 140% of MNRP.  I can't find the Medicare fee for the E0486.  I have gone the Medicare site but I'm lost.  Should the patient pay in full up front because we are not in network.  Should I ask for a gap exception so they pay above the Medicare rate?  Any help will be greatly appreciated!

I finally spoke with someone from CGS and the E0468 is not covered.  So now I'm back to square one.  I called UH back and the patient has met their out of network deductibles.  I don't know if that helps...
« Last Edit: November 04, 2016, 10:38:12 AM by twells »


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Re: Need help billing E0486
« Reply #1 on: November 04, 2016, 09:52:08 PM »
By Googling E0468, I found several older articles/posts where it was said that this code is covered under the DME portion of Medicare, but when I went to various DME fee schedules to look for an allowed amount, it was not on any of them, so it may be that DME no longer covers this code, therefore trying to determine a fee using the Medicare allowed amount will be impossible. I even looked back at old fee schedules.

This article:

says allowed amounts run from $2500-5000 per case. But....I don't know how reliable that is.


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Re: Need help billing E0486
« Reply #2 on: November 05, 2016, 09:43:13 AM »
Bottom line if the provider is out of network then the patient is responsible for the fee.  You can submit to their insurance for them as a courtesy.  It is nice to be able to advise the patient what their insurance will cover but if you are unable to get that information then the patient may be able to try from their end.  At any rate the payment usually goes to the patient directly when the provider is out of network. 
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Re: Need help billing E0486
« Reply #3 on: November 08, 2016, 09:59:40 PM »
There is no medicare published fee schedule for E0486 but it is a covered benefit.  MNRP for UHC is Maximum Non-Network reimbursement policy which is either a percentage of Medicare, 50% of billed charges or U&C for out of network providers. I know it's hard for dental providers when it comes to medical for OON because with dental you know exactly how much is going to be paid. As an OON medical provider you have to wait until the claim is submitted (depending on the insurance). You should always try for a gap exception but even if that is approved, they will not tell you an allowed price. I would say establish a price in your practice that you collect from the patient and bill a courtesy claim. All I do is bill medical for dental providers. Feel free to reach out if you need help  :)