Patricia Donegan
Contributor
Is anyone finding recent issues with AETNA? For OBGYN - when patients have a split in their global prenatal- we will bill out the antepartum care only codes 59425 (4-6 visits) or 59426 (7+ visits ) - depending on the # of visits patient had (less than 4 visits are converted to EM codes and not this code) The code is billed on one line- with from and to dates (ex: 8/03/22 to 12/19/22) and as 1 unit only. This is the way this code has always been billed to insurance - and is how ACOG and every payer advises to bill . Over the last several weeks- maybe even 2 months - I have been denied by Aetna for an odd reason- and one that I absolutely have not been able to correct! Further- I call Aetna repeatedly at 1-800- 624- 0756 - but simply cannot get a live representative- I keep getting pushed to a fully automated line and advised to go onto to Navinet. Which I do - but still cant get resolution. This is the denial in Navinet- cpt 59425 is billed- 1 unit- date 8/03/22 to 12/19/22 - and the error W25 -does anyone know what they want to get this claim thru? Do you list individual visit dates on the claim? by line item? Would you list 59425 on each DOS ? Is there something with the diagnosis that needs to be listed for each date? Maybe the gestational weeks for each visit? I could really use some advice if anyone else is having this issue. How do you respond to this W25 pend? I am getting NO WHERE! HELP!!!!
Contractual ObligationW25:
Number of units does not match date span or modifiers. Please re-submit with individual date of service with matching modifiers and units. We need additional information in order to consider this charge. The information we need is explained on this statement. Please send us this information within 45 days from the date you receive this statement. We will make our benefit determination either (1) within 15 days after we receive the information we need or (2) within 45 days from the date you receive this statement, whichever is earlier. If we do not receive the information we need, this charge will be denied. The effective date of the denial will be the 46th day after the date you receive this statement. The basis for the denial will be that we do not have the information we need to consider this charge. You will have a right to appeal that denial at that time. For claims submitted from North Carolina, you have 90 days to respond to the request for information. If you fail to respond in 90 days, and receive a denial notice, you may submit the requested information within one year from the date the claim was denied and your claim will be reopened. This does not apply to Federal Plans. For claims submitted from Texas, we will make our benefit determination either (1) within 15 days after we receive the information we need, or (2) within other applicable statutory time periods that apply to you. For applicable provider claims submitted from Texas, your claim will remain open until you provide the requested information. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND - W25]
59425 | | 1.000 | W25 |
Contractual ObligationW25:
Number of units does not match date span or modifiers. Please re-submit with individual date of service with matching modifiers and units. We need additional information in order to consider this charge. The information we need is explained on this statement. Please send us this information within 45 days from the date you receive this statement. We will make our benefit determination either (1) within 15 days after we receive the information we need or (2) within 45 days from the date you receive this statement, whichever is earlier. If we do not receive the information we need, this charge will be denied. The effective date of the denial will be the 46th day after the date you receive this statement. The basis for the denial will be that we do not have the information we need to consider this charge. You will have a right to appeal that denial at that time. For claims submitted from North Carolina, you have 90 days to respond to the request for information. If you fail to respond in 90 days, and receive a denial notice, you may submit the requested information within one year from the date the claim was denied and your claim will be reopened. This does not apply to Federal Plans. For claims submitted from Texas, we will make our benefit determination either (1) within 15 days after we receive the information we need, or (2) within other applicable statutory time periods that apply to you. For applicable provider claims submitted from Texas, your claim will remain open until you provide the requested information. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND - W25]