Wiki Denying for No Referral - Outpatient Hospital Midwife / OB

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rpettigrewcpc

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Trying to figure out if there's a way to get around a problem I'm running into with referrals.

We have midwives at our hospital in L&D that see patients when they're unable to get in with their regular OB. Kind of like an Urgent Care setup, but it's in the hospital, we're not an Urgent Care facility.

The majority of insurances I don't have a problem getting payment. However, BCBS and Tufts HMOs, I get every claim back for no referral.

We use the codes 99201-99205 and/or 99211-99215 for these visits, unless they're admitted to observation.

I've considered using 99281-99285, but the majority of the time, they don't come in through the emergency room, so this technically isnt accurate.

The POS is 22 for outpatient hospital.

Any thoughts or advice on how to get around the need for referrals on these? These are patients with spotting, cramps, possible early onset labor, things that they obviously don't get referrals for.
 
sounds like those two insurances require approval from patients PCP for the visit and the claim will need the PCP'S UPIN or referral number on it. For box 17.
 
I could try to be sure that the PCPs NPI is on the claim when billed and see if they come back this way... however, there's no official referral as the patients are seen on an 'urgent' basis so-to-speak.

There's got to be a way to get the insurances to recognize that these aren't standard visits. You'd think that the diagnosis of dehydration, pre-term labor, spotting, etc would make that obvious. :p
 
Call them :) They may have their own special policy in place (special modifier, special vcode, etc) that your office may need to log for future reference. It happens.
 
BCBS Georgia does not credential midwives. We have been instructed to bill 'incident to'. Of course, you must satisfy 'incident to' requirements.
 
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