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Capitation Accounts

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kayfly:
I bill for a low vision clinic and since I have not gone to school to learn coding (I am in the process of doing that though) I get confused when capitation denials come in. I received two last week from Medicare: denied due to capitation.  How do we get paid for our service or do we? I get so confused with these and I just don't know what to do. Thank you for any help!

Michele:
IS the patient enrolled in a Medicare Advantage Plan?

kayfly:
Hi, the first one is a Medicare/Medicaid so it went to Medicare and came back with that message. The second one is Humana Gold who I billed first and it said it was unprocessable THEY sent it to Medicare and I got the denial from Medicare for the capitation reason.

Michele:
Have you looked the patient's up on Connex to see what CMS shows they have?  It sounds like they have an Advantage plan and you are just billing the wrong one.

Weird on the Humana one.   I've never seen them forward information to Medicare.   ???

kayfly:
I have no idea what Connex is but I will look it up today and check it out, thank you! Medicare/Medicaid...no advantage plan there! The Humana sending to Medicare IS weird for sure it just sounds as though I need to make some calls. I get confused with these capitation issues. Thank you for the suggestion though and I will do that today!

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