Wiki Medicare Allowable Fee Schedule

[lruby20]

How do I appeal a claim in which two vaccinations given to a child were not paid by the insurance? 90710 (MMRV) and 90723 (DTaP-HepB-IPV) are appropriate for this child. The insurance, TPA, states they pay 150% of the Medicare allowable. However, these vaccines are not on the Medicare fee schedule. Per the CMS website they are not covered by Medicare. The insurance wrote off the entire balance of both vaccinations. There is no patient responsibility as well. What do I use as my reasoning for these vaccines to be paid? They are appropriate for this patient per the CDC and AAP.

 

[sls314]

How do I appeal a claim in which two vaccinations given to a child were not paid by the insurance? 90710 (MMRV) and 90723 (DTaP-HepB-IPV) are appropriate for this child. The insurance, TPA, states they pay 150% of the Medicare allowable. However, these vaccines are not on the Medicare fee schedule. Per the CMS website they are not covered by Medicare. The insurance wrote off the entire balance of both vaccinations. There is no patient responsibility as well. What do I use as my reasoning for these vaccines to be paid? They are appropriate for this patient per the CDC and AAP.

I would start by looking at the contract with the insurer and seeing how it addresses reimbursement for codes that are not on the Medicare physician fee schedule.

Generally, if an insurance contract is based on a percentage markup of the CMS fee schedule, the contract will have language that specifies an alternate pricing methodology for services that don't have a CMS fee schedule rate.

For example, it could reimburse those line items at a percent of charges, or it could substitute the Medicaid fee schedule amount. It really just depends on the contract that was signed with the insurer.