Wiki Medicare guidelines for colonoscopies

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ngastroent

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We had a patient set up a screening colonoscopy who uses a Medicare replacement plan with Medica. As per usual, I went onto Medicare's website to verify that they're eligible to have a screening colonoscopy. It did confirm that the patient was eligible as of 6/01/2019. Patient had the procedure and I submitted the claim. We got a denial stating the patient was ineligible. I called for an explanation and was told the patient just had one in November of 2019 that they covered. Does anyone know where I should go from here? I have the printout from Medicare that shows the patient was eligible, so it's an error on their side somewhere. But since they're not the ones to process the claim, not sure how to fight Medica as have found out since that they are correct and the patient did have one elsewhere in 2019.
 
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If you looked up on C-Snap it only shows eligibility for Traditional Medicare. You would have to call the patients Medicare Replacement plan to see if they're eligible with them.
 
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Interesting! When I was trained in 10 years ago, I was told it still gets filtered through Medicare and gets updated when one is done. Thank you for letting me know!
 
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ngastroent said:
We had a patient set up a screening colonoscopy who uses a Medicare replacement plan with Medica. As per usual, I went onto Medicare's website to verify that they're eligible to have a screening colonoscopy. It did confirm that the patient was eligible as of 6/01/2019. Patient had the procedure and I submitted the claim. We got a denial stating the patient was ineligible. I called for an explanation and was told the patient just had one in November of 2019 that they covered. Does anyone know where I should go from here? I have the printout from Medicare that shows the patient was eligible, so it's an error on their side somewhere. But since they're not the ones to process the claim, not sure how to fight Medica as have found out since that they are correct and the patient did have one elsewhere in 2019.
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ngastroent said:
Check and see if maybe the PCP
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ngastroent said:
We had a patient set up a screening colonoscopy who uses a Medicare replacement plan with Medica. As per usual, I went onto Medicare's website to verify that they're eligible to have a screening colonoscopy. It did confirm that the patient was eligible as of 6/01/2019. Patient had the procedure and I submitted the claim. We got a denial stating the patient was ineligible. I called for an explanation and was told the patient just had one in November of 2019 that they covered. Does anyone know where I should go from here? I have the printout from Medicare that shows the patient was eligible, so it's an error on their side somewhere. But since they're not the ones to process the claim, not sure how to fight Medica as have found out since that they are correct and the patient did have one elsewhere in 2019.
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Check and see if the PCP did a cologuard at their annual visit. Code 81528 as this would replace the screening benefit. We have been running into this a lot with the PCP offices not informing the patient that this test would count as their colonoscopy screening benefit.
 
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