Medical Billing Forum
Billing => Billing => : kjoiner December 17, 2014, 08:02:51 PM
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This question is for my Skilled Nursing Facilities billers out there - Has anyone received a denial from BCBS (specifically Michigan) citing a duplicate of service due to the fact that the plan guidelines only allow a maximum of 2 providers of any specialty to treat the patient per week?
We were given this denial reason by BCBS of MI and it is the first we've ever heard of it. We were also told that the claims are paid on a first come first served basis, therefore if 3 or more providers billed for services that week only the first 2 claims would be paid and all the rest would be denied.
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Heard of that for consults on same day.. you don't specify if this was same day or not.
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It was for different dates of service. The BCBS rep told us only 2 providers were allowed to see the patient per week, or that 1 provider could see the patient twice in a week but any claim(s) beyond 2 per week would be denied. They also informed us because we are out of state, we have no ability to appeal the decision even though the provider is contracted with our state BCBS. Have you or anyone on this forum dealt with BCBS of MI and if so, can you offer any suggestions on how to appeal this?
Thanks.
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It was for different dates of service. The BCBS rep told us only 2 providers were allowed to see the patient per week, or that 1 provider could see the patient twice in a week but any claim(s) beyond 2 per week would be denied. They also informed us because we are out of state, we have no ability to appeal the decision even though the provider is contracted with our state BCBS. Have you or anyone on this forum dealt with BCBS of MI and if so, can you offer any suggestions on how to appeal this?
Sounds like a plan provision. Is this an ERISA plan? You can bill patient and have them responsible for the appeal but if it's a plan provision your most likely out of luck.