Wiki UHC Flu vaccine denials

[ajohannsen]

UHC Medicare Advantage for 2024-25 90658 is reinstated but getting denials from UHC. Should we be billing the Q2038 for Medicare Advantage still ?

 

[caseylashaek]

Thank you for this question as we are still getting denials on this and need clarification.

 

[dpigamd]

I work for a Clinical Integration Network in Dallas. Several of my practices brought to my attention that CMS and MA plans were denying reimbursement of CPT 90658 between DOS 08/01/2024 to 10/07/2024. CMS were holding payment of the flu vaccine (CPT 90658) due to a pricing error. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-09-19-mlnc#:~:text=Influenza Vaccine: Holding Claims for CPT Code 90658,-CMS is aware&text=We're holding claims for,need to take any action.

CMS says your MAC will reprocess any of those claims impacted by that 90658 denial. Has anyone else noticed the same thing as it looks like it has impacted MA plans as well? If so, what should I advise my practices to do, appeal?

 

[ajohannsen]

I am based in Iowa and Illinois. We are getting denials from Medicare Advantage United Healthcare they are paying the bill except for 90658 stating not covered. We made calls to UHC they only state will look into it. We did an appeal and was also denied again.

 

[dpigamd]

I am based in Iowa and Illinois. We are getting denials from Medicare Advantage United Healthcare they are paying the bill except for 90658 stating not covered. We made calls to UHC they only state will look into it. We did an appeal and was also denied again.

See if you can escalate the unresolved UHC MA claim for external review to your contracting entity, ACO, or IPA and be sure to cite the CMS pricing error for CPT 90658 that I referenced.