Wiki Aetna and Allergy serum

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lfontanez

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Atlanta, GA
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Hi all. I work at an allergist, and we are getting nothing but denials since September for all of our new start allergy shots patients. Every. Single. Claim. has been denied. We are within their mixing limits; they have demanded records for each patient, which we have provided. Aetna is becoming nick-picky and began denying because our records didn't include lot numbers, then they deny because the provider hasn't actually signed every.single.page., once we've corrected all of their reasons for denial - I'm still getting denied, with "original decision maintained". Is any anyone else having this issue? The claims agents are no help and are just making things worse. Anyone had any success in getting new starts approved and paid?
 
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NLCrew said:
Are you including the NDC numbers on the claims?
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susankaufman@yahoo.com said:
Hi, we are getting the same thing here at our practice. Please let me know what you may have found out and reply so hopefully together we can get a resolution. thank you
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I have had zero luck so far. First they deny for records. You send records then they deny because the Dr didn't sign every page, even though our pages state electronically signed and CMS states that is valid. You fix that. Then they'll say, well the allergy mixing note didn't state that the Dr was in office and supervised the mixing of the vials. You fix that. Then they'll say you didn't include all of the manufacturer names, lot numbers and expiration dates for the antigens. Then you fix that. Then, they finally state that the mixing doesn't fall within their Aetna CPB and that it is not a covered service. That's when more of the silliness happens. Because you'll ask them to tell you what in the CPB you are violating and they cannot answer. You go round and round with claims rep and get no where. You pull up the CPB and see that nothing has been exceeded. You are then told to appeal the denial, but what are you appealing if you don't know the reason? You appeal, show them the CPB where nothing has been violated - valid billed quantities, valid billed amounts, valid and covered icd-10 codes. And the appeal will be denied. Then you ask why was the appeal denied and no one can answer it. --This has been my saga since September. I was finally able to with someone, about a week and a half ago, and she very helpful. She said that when a claim is denied, the processor is supposed to put on the claim what you are in violation of and where it can be found for the reps to see and tell the provider. This one particular claim, there was nothing available for them to see for the reason for the denial and the claim was "locked" so no one could manually override the decision made by the processor. She them pulled up the CPB herself, and could not find anything we were in violation of. She went back and forth with her supervisor, who then sent me to the appeal dispute department but they said it was a claims processing error and it needed to go back and be corrected (exactly what I've been saying for 6 months now!). So, this one claim, has gone back for internal review for incorrect processing. I told her it was just for 1 provider in the office and it was for all of his new starts. She said they'll pull his NPI and, supposedly, fix the other claims also.
 
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lfontanez said:
I have had zero luck so far. First they deny for records. You send records then they deny because the Dr didn't sign every page, even though our pages state electronically signed and CMS states that is valid. You fix that. Then they'll say, well the allergy mixing note didn't state that the Dr was in office and supervised the mixing of the vials. You fix that. Then they'll say you didn't include all of the manufacturer names, lot numbers and expiration dates for the antigens. Then you fix that. Then, they finally state that the mixing doesn't fall within their Aetna CPB and that it is not a covered service. That's when more of the silliness happens. Because you'll ask them to tell you what in the CPB you are violating and they cannot answer. You go round and round with claims rep and get no where. You pull up the CPB and see that nothing has been exceeded. You are then told to appeal the denial, but what are you appealing if you don't know the reason? You appeal, show them the CPB where nothing has been violated - valid billed quantities, valid billed amounts, valid and covered icd-10 codes. And the appeal will be denied. Then you ask why was the appeal denied and no one can answer it. --This has been my saga since September. I was finally able to with someone, about a week and a half ago, and she very helpful. She said that when a claim is denied, the processor is supposed to put on the claim what you are in violation of and where it can be found for the reps to see and tell the provider. This one particular claim, there was nothing available for them to see for the reason for the denial and the claim was "locked" so no one could manually override the decision made by the processor. She them pulled up the CPB herself, and could not find anything we were in violation of. She went back and forth with her supervisor, who then sent me to the appeal dispute department but they said it was a claims processing error and it needed to go back and be corrected (exactly what I've been saying for 6 months now!). So, this one claim, has gone back for internal review for incorrect processing. I told her it was just for 1 provider in the office and it was for all of his new starts. She said they'll pull his NPI and, supposedly, fix the other claims also.
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Thank you so much for replying to me. They are denying ours and giving us the same answer for everything. We would like to pull together, so to speak, and be on the same page as your practice. This way we can all send in the same info and possibly to the same reprocessor. Do you mind giving me your contact information as my RCM manager would like us all to talk. my number is 470-361-2369. thank you again!
 
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Similarly, we are not even breaking even with the cost of the allergy serum and insurance reimbursement. Is there a J-code for allergy serum to bill along with 95117 and 95165?
 
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With regards to the new start serum mix billing for Aetna, we were also having issues and we had to go straight to our Aetna rep who, then had to go to the Claims processor to get EXACTLY what was needed in order to satisfy the billing of serum. We jumped through a lot of hoops but are finally being paid. We found that the key upon your original submittal is to make sure that you are sending in progress notes going back to when they originally tested to satisfy the CPT 0038 which states why allergy testing was needed in the first place. along with the original testing forms. We then had to go back to the referral notes (if applicable) and document any and all conservative measures tried by the patient, including meds, sprays, rx's, etc. to justify the testing. This is ridiculous but, unfortunately, necessary. We then have to make sure to have the manufacturer, lot# and expiration dates of ALL of the allergens in the serum mix which is cumbersome but your shot room clinicals should be able to provide this. Then you have to make sure that the progress notes have signatures on them. We also found that a cover letter giving all of this detailed information in bullet point format helped push this along. Sometimes it means a 45-50 page MR submission but it has been getting the claims paid which is what we need. But pay attention to the timelines. You have 45 days to do this and then if it denies, you have to go straight to appeal, reconsiderations are not an option for MR denials. Hope this helps.
 
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So, we have had success AFTER we began sending records - similar to the above message. I send in a fax cover sheet, patient demographic page, the 1st office visit note (which includes the appropriate history, current meds, doctor recommendations and the timeframe for shots - yes, we've been told that is also a reason they will deny) the allergy skin test results, any signed immunotherapy consent forms, the allergy serum prescription for that vial, mixing logs plus a copy of the CMS-1500 form. All are signed by the doctor - visit note, allergy test results, serum logs and prescription. In total, I usually fax about 22-23 pages.
BUT I just got a letter from Aetna, they are trying to recoup the money they paid for one of these DOS. Reason stated was that it is an exclusion but when I pushed back with a claims rep, she said that it is falling under their Fraud/Abuse policy.
 
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