Based on my resources, in order for the pathology to be covered in full it must have a 33 or PT modifier. I have not sent the claim for adjustment review..however, I do not believe an adjustment would occur if I did based on processing error. Potentially, one of the following diagnosis codes could cover the claim as preventive as well: Z12.10 or Z12.11 or Z12.12 (not submitted on any of the claims)So I guess what I'm asking is; is a claim re-submission ever appropriate for the technical component of the claim, either with an updated modifier or an updated Dx code?
To clarify, I work in customer care of the members health insurance company. This allows me access to the claims. The member called with a bill.
When I discuss this with the provider, I am going to ask why a diagnosis of Z12.10 or Z12.11 or Z12.12 or a modifier of PT/33 is not appropriate for this members screening. And request the chart notes on the services to be reviewed to see if a re-submission may be appropriate.
From my understanding, a claim can only be appealed if there is a denial. This claim is not denying and the member called in because it generated a copay. Perhaps you have some insight what capabilities the providers have?
I can only speak of the members appeal rights. Thanks.