Our office is Out of Network with BCBS. When we submit claims for Radio Frequency Abalations, often they are denied for Medical Necessity. There are a number of guidelines that need to be met to show medical necessity - 3 months of conservative therapy, previous Medial Branch Block has reduced pain by 50% or more, pain is not radicular, etc. The problem is that when I call to find out the specific reason for the denial, which guideline is not being met, they never give me an answer, other than the claim was denied correctly. And they absolutely will not put a supervisor on the line to resolve the issue. When I insist on a supervisor, they put me on hold, and leave me there, and after 30 minutes the call drops. It's hard to submit an effective appeal letter when you don't know the specific reason for the denial. Any suggestions for resolving this?
John Methgen, BS, CPC-A, CPB
John Methgen, BS, CPC-A, CPB