Wiki Cigna-Reimbursment for 'unlisted' code 38999

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rubisaavedra

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Hello, if there is anyone who is familiar with Cigna reimbursements for unlisted code(s) or works for cigna, please help.
We are a non-contracting provider with Cigna. We obtained prior authorization for the 'unlisted' code, billed Cigna, and they paid very very low.
we tried to get them to re-process the claim under the patient's out of network benefits, they sent the claim to an outside 3rd party administrator to possibly
negotiate the claim, but they would not pay as we initially expecting. We are trying to get cigna to pay without going through the appeals process, but I don't know if we may just have to. Thank you anyone, for your input.
 
You would need to balance bill the patient for the difference. If you accept the third party rate you are bound to accept it as payment in full (less any copay/deductibles which will go to patient). I believe the proper protocol would have been to try to do this before providing the service.
 
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correct, the patient is fully aware of their oop expenses, and yes the agreement would bind us to only bill the patient for their responsibility. Due to the nature of this procedure, Cigna was aware that the bill would be considerable, and therefore we, as the patient expected cigna to pay more than what they paid, and offered..
thank you for your input. I appreciate it.
 
I cant answer for Cigna but the payer I work for if we received an appeal disagreeing with the rates, we wouldn't be able to do anything unless we could convince the provider to take a lower rate. I'm currently involved with the PA process for Unlisted codes and we usually have the provider give us the closest equivalent code and price based off that. Now that I think about it more I would definitely ask how they assigned the rate to the unlisted code before continuing.
 
okay thank you! that does help me, and seems like I will be doing an appeal then, to see how they are coming up with that rate, and what are they comparing it to..
thank you again!
 
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