Wiki Billing Questions Highmark Speech Therapy Claims Denials

[cnjacobs15]

So this is more billing related rather than coding related... But I am at a loss and figured it would not hurt to ask. I work for large FQHC as a Coding and Billing specialist. We bill for Speech and Occupational Therapy.. These kid's are seen multiple times a week and usually exhaust their benefits in a short period of time but have the option to continue therapy even if their insurance will no longer pay.

So for our local Highmark specifically we will submit for the authorization and received a denials with the reason being "Benefits Exhausted". Which is an accurate reason to deny the authorization once they meet their visit limit. The issue we are having is even with the benefit denial authorization number attached Highmark denies the claims for CO197 - "The patient's coverage required preauthorization for the reported service. Since the authorization requirements were not met, no payment can be made.". When that happens we start claim investigations stating that we attempted to obtain authorizaton and received a benefit denial and that the claim should reflect the benefit denial requesting them to reprocess with a PR119-Benefits Exhausted claim denial code. Occasionally they will automatically reprocess but most times they tell us that the authorization was denied and not valid and we have to do multiple investigations until they finally reprocess.. and every once in a while they will automitcally denied the claim as PR119 so it is just not consistent!

Has anyone else had this issue? Or any suggestions?

Thank you!!

 

[leagle]

We have a slightly similar situation with BCBS of Michigan. Do you have a local provider rep that you can contact? It's most likely an automatic system denial that would require updating that I would think only they could help facilitate. Or, be brave and ask for a supervisor/manager and complain every.single.time. I find that some reps get it and will have the claim properly adjusted and others don't understand leading to another wrong denial and more work calling back...

 

[cnjacobs15]

So unfortunately the process our local enforces we are required to complete 3 unsuccessful claim investigations on each claim before we can request a claim escalation with the provider rep! Which our hope is they will eventually get tired of it and figure out why it’s happening! The claims add up very fast we have a family of 3 children who are seen 2 and 3 times a week alone. Along with a few other patients. Each time our Highmark EFTS are posted there are at least 20 new CO197 denials posted for this reason. Thank you so much for the feedback and response if anything at least we aren’t alone! These Blue cross plans seem to make everything difficult!

 

[TThivierge]

Hello
Ahh why not get provider to complete the new authorization as soon as done or week in advance BEFORE it expires or runs out then fax in with cover letter explain the need to continue Speech Therapy,.Get a name of person you deal with all the time for billing or preauthos done when called in at payer.. Are you using modifier GN with CPT code while listing referring doctor on claim too? Using most detailed dx code all the time in showing reason why pt. need this treatment & minutes on record. As side note list treatment date which happen before on new claim to show it is ongoing care. Also check out modifiers 96 and 97 may help too. I hope this data helps you.
I hope I helped you
Lady T

 

[cnjacobs15]

Hello
Ahh why not get provider to complete the new authorization as soon as done or week in advance BEFORE it expires or runs out then fax in with cover letter explain the need to continue Speech Therapy,.Get a name of person you deal with all the time for billing or preauthos done when called in at payer.. Are you using modifier GN with CPT code while listing referring doctor on claim too? Using most detailed dx code all the time in showing reason why pt. need this treatment & minutes on record. As side note list treatment date which happen before on new claim to show it is ongoing care. Also check out modifiers 96 and 97 may help too. I hope this data helps you.
I hope I helped you
Lady T

So for the authorizations. we are submitting them prior to running out. but the authorizations are being denied as the benefit max has been reached. which is correct since they have met their visit limit.. But they want to continue to be seen for therapy.. With the benefit denial authorization we are expecting the claim to deny with a patient responsibility benefit denial as well since they do have a secondary medicaid insurance in which will pay when the primary denies the claims as PR119. But Highmark is not denying with a benefit denial. They are denying for CO197 as if we did not submit for the authorization at all.. If that makes sense..

As for a person.. Due to very very high volume of patient's we see the authorization staff at the Pediatric developmental center use Highmarks Authorization portal predictal to submit them..
Referring provider on claim - yes.
Diagnosis codes are detailed- yes and they are also the same we use for submitting the authorizations.
As for Modifier GN we are not using that for Highmark.. but i am familiar with those for UHC.. But i will try to submit some of the Highmark claims with them it doesn't hurt to try!
thank you for the feedback!!! i really appreciate it.

diagnosis codes, diagnosis coding