General Category > General Questions
PREVENTIVE COLONOSCOPY PATHOLOGY (TC) GENERATING COPAY Z86.010
PMRNC:
--- Quote ---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.
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Be careful if they screen calls. Instead of asking them why they didn't code something a certain way I would tell them to appeal with the notes and leave it at that. Even with hints it can be encouraging fraud as they could take your hint and change documentation. JMHO..I was a senior tech claims advisor at the last carrier I worked for. Rep calls were always screened, they didn't always review all of them but they could at any time. You also never know if a diff claims person comes along to review the notes and denies, first thing doctor is going to do is call back and whether you said it or not, they will say you told them what to do. Now working for doctors I constantly have patients either LIE or misunderstand the carrier, calling me and telling me the carrier said they didn't code the visit right. HAPPENS all the time!!!
leanersnail4:
You are absolutely right, I did not think about the call being pulled. I will need to revisit my strategy. I want to stay compliant and follow correct protocol.
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.
PMRNC:
--- Quote ---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?
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Any time a claim pays less than the "billed" charges there is an adverse benefit and can be appealed. I too suffered the "insuarnce company brain wash" <g> I still miss it though..:) :)
They can appeal a claim they believe was processed incorectly.
--- Quote ---I can only speak of the members appeal rights. Thanks.
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On the contrary.. all you have to do is think on the side of the patient and/or the provider. Anytime they "think" they were not paid fairly they can appeal. Of course that doesn't mean the claim will pay upon an appeal but they can appeal. When i went from being claims examiner to billing I had to do a lot of adjusting on how I thought of claims. I had to jump over to the other side and it wasn't always easy.
leanersnail4:
Thank you for insight on the provider protocol. I need to know the "why" behind things and I want to communicate the correct answer to the patient (while remaining compliant). Claims often process against expectations and I am making every effort to ensure the members contract is being honored.
I have been working in health insurance with a focus on member care for three years now and I still believe they can only appeal denied claims (except Medicare members). Although, I agree with the idea a patient should be able to appeal any claim that they do not feel the insurance company is not paying fairly, this does not seem to be the case.
For what its worth, I performed a quick google search and the results support appeal rights only exist for denied claims as well. Would you happen to have any resources which support your statement that a member can appeal any claim they do not feel is processing correctly?
PMRNC:
My intent isn't too argued but I'll give you an example. A surgical procedure for $900 is submitted, provider is non-par. Insurance company pays $600 with $100 going towards the patient's deductible and $500 is above U&C. That $500 is what is called an "adverse" benefit. If you look at any of the EOB's your carrier produces you will notice they use the word "Adverse benefit" (Especially on ERISA group health plans) An adverse benefit determination is defined as;
An "adverse benefit determination" is: (1) a denial, reduction or termination of a benefit; (2) a failure to provide or pay for a benefit (in whole or in part); (3) a denial of participation in the plan.
An appeal can be made on any adverse benefit determination. Anything NOT paid in full can be appealed. Again, not saying it will be paid, just that member can appeal.
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