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Billing Secondary for LPC, When Medicare is Primary
mpl:
This is my first time asking a question. I love this forum and use it A LOT. I hope that this isn't a repeat, but I haven't found an answer yet and hope that someone can point me in the right direction.
I bill for Mental Health and Substance Abuse providers in WI. One of my providers is an LPC and sees a client who has Medicare as their primary and Dean Medicaid as their secondary. Another provider (also an LPC) sees a client with Medicare as primary and iCare Medicaid as secondary. I've not had problems in the past just billing directly to the secondary insurance, but am starting to get denials coming back from both Dean and iCare requiring that I have a Medicare denial attached to the claim. Since I can't submit to Medicare because an LPC isn't eligible to be a Medicare provider, I can't provide them with this. I've contacted both Dean and iCare to explain this, but neither of them are budging. Initially iCare told me that I needed to put 'M8' in box 11 of the HCFA form. I did this and some claims paid, but others did not. On top of it, iCare has now recouped several claims that they had previously paid, insisting that it has to be billed to Medicare first.
Another biller who I've worked with passed along a Medicare letter to me (see attached document). She said she will sometimes attach a copy of it to the claim and that usually works to get the claim paid. I've tried locating this document on the Medicare website in hopes of having a more updated (and cleaner, easier to read) version of it so I can use it for citing, but cannot find it.
So two questions....
1. Is there a code or modifier or something that I'm supposed to be putting on the HCFA to flag it to indicate that the Medicare policy can be bypassed due to the provider's credentialing?
2. Does anyone else know where I can find the Medicare letter?
ANY help would be greatly appreciated. Thanks so much!!
Michele:
--- Quote from: mpl on January 03, 2019, 12:57:03 AM ---So two questions....
1. Is there a code or modifier or something that I'm supposed to be putting on the HCFA to flag it to indicate that the Medicare policy can be bypassed due to the provider's credentialing?
--- End quote ---
Have you tried the GY modifier?
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
We use that when we bill a commercial carrier for acupuncture since acupuncture is not a covered Medicare benefit.
--- Quote from: mpl on January 03, 2019, 12:57:03 AM ---2. Does anyone else know where I can find the Medicare letter?
ANY help would be greatly appreciated. Thanks so much!!
--- End quote ---
There was no attachment. I don't believe there is a way to include an attachment on the forum. I'm not familiar with the letter you are referring to. Does the other biller have a copy you can just use?
The only other thing I can recommend is printing out the copy of the page from the CMS 855I that shows the types of providers that Medicare will enroll with a letter stating that LPCs cannot enroll in Medicare therefore claim cannot be submitted to Medicare.
I hope that helps! Keep us posted.
mpl:
I haven't tried that modifier. Is that something that can be used to indicate that the service is typically an allowable Medicare service, but the provider isn't participating, so that's why it isn't allowable in this circumstance? I'm using CPT code 90837.
Sorry about the confusion on the attachment...I meant to take that out of the post. I had initially tried attaching it, but it wouldn't attach. I do have a copy of the letter from the other biller, but it's pretty old and almost to the point of being difficult to read. I was hoping to find something that had a specific date on it as well, to show that it was up to date. I'll probably just use what I've been given and add a copy of the list of providers who can't enroll in Medicare.
Michele:
I am not aware of a modifier that specifically says "provider is not allowed". That is the closest modifier I know of. That is what we use for the acupuncturist we bill for.
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