Wiki Code 11102 + 11103 Denying Under Physician's Assistant

[SamrPen]

Medicaid plan through Banner University Family Complete Care is denying codes 11102 + 11103 with a PA on the claim stating "99353 AHCCCS P353: PROVIDER TYPE NOT ELIGIBLE." The claim pays however when we resubmit under an MD as opposed to the PA originally on the claim. This issue began in Jan of 2023. Previously, all claims were being paid under our PA's in 2022. Has anyone come across this issue, or is there a new rule affecting reimbursement for PA's that I am not aware of for 2023? I have attached a redacted claim as reference. Thank you.

 

[thomas7331]

It appears to me to be a payer error (likely a claims system programming error) since, on the attachment you shared, they have allowed the add-on code but denied the base code for the same procedure, which is contradictory if they are intending to disallow that procedure due to the provider type.

FYI unless you submitted incorrectly on the initial claim, I would strongly advise against resubmitting claims with a different provider as a means to get payment as this could create other problems for your practice.

 

[SamrPen]

It appears to me to be a payer error (likely a claims system programming error) since, on the attachment you shared, they have allowed the add-on code but denied the base code for the same procedure, which is contradictory if they are intending to disallow that procedure due to the provider type.

FYI unless you submitted incorrectly on the initial claim, I would strongly advise against resubmitting claims with a different provider as a means to get payment as this could create other problems for your practice.

Thank you very much for this information! I will pass this on to my management.