Wiki Denial of 95165

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dsley

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I have received several request for recoupment from UHC on code 95165 because the member does not have an injection claim 7 days prior to or 30 days after the antigen claim. I disputed the request but received notice that the denial stood. We prepare antigen for patients that we do not give injections to. Has anyone else seen this issue?
 
Let me see if I understand this. You prepare, but don't administer the antigen. Do you provide the antigen directly to the patient, or to the provider who administers the antigen? I am wondering if that provider should be paying you for the antigen, and billing the antigen and injection themselves, on the day of delivery. I am not sure if you can bill the patient's insurance if you simply do the preparation, or if the payer has their own rules about that. And in that case, do you bill their prescription plan, since no therapeutic service was done?
 
Denial if 95165

We prepare the antigen, 95165, then do the injections for some patients, 95115 others we provide the antigen in the vials for self administration. We've been providing this service for many years with no problem. This is specific to UHC and I've not seen this with all UHC patients or any other payers.
 
Does UHC have a payment policy that indicates that if you prepare the antigen you also must administer it? That would be my only suggestion. Although the codes are separate, I wonder if they have some sort of funky requirement. I'd contact your provider rep and see if they can shed some light, or check out their website to see if they have any published policies.

I think what they're saying is that although you prepared the antigen...the patient's claim for the administration didn't get submitted. So they won't pay for the antigen that the patient isn't getting. That's not really under your control, but perhaps for UHC patients, you may want to consider administering the antigen yourself so that you know they're getting it.
 
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dsley said:
I have received several request for recoupment from UHC on code 95165 because the member does not have an injection claim 7 days prior to or 30 days after the antigen claim. I disputed the request but received notice that the denial stood. We prepare antigen for patients that we do not give injections to. Has anyone else seen this issue?
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When you disputed the request, did you supply the injection record also? If the patient gets their injections somewhere else you must get the records from that doctor or if they administers them at home the patient needs to supply the record to you.

We have had this issue also but when we showed that they were actually receiving injections and not sublingual drops UHC cancelled their recoupment.
 
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