Wiki UHC NDC max unit denials

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shanamarie

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Has anyone had issues with UHC and a new policy regarding max billing units per NDC? We have several claims, random drugs denying stating we are over the max units.
Ex: Botox 155 units given and 45 units wasted. We would bill J0585x155 and then J0585(JW)x45. They are stating that we are 55 units over the max for that NDC. We are using 2 vials so technically the max billing is 200 units total. To break this down on 3 lines doesn’t seem right to me either, and I’m sure they would likely deny as a duplicate if I sent it on 3 lines. Thoughts?

 
We are receiving denials as well. I know they are wanting single dose vials listed with JZ or JW modifier. I am working on finding out if 2 or more vials are used if they are wanting the J code listed more than once with JZ and JW modifiers and corresponding units. I am very confused and working with UHC to get answers. These are part of the NEW Oct 2023 CMS guidelines that came out, it is just not clear on coding when dosing is more than 1 vial of the same drug
 
monika.daza@hcidtx.com said:
We are receiving denials as well. I know they are wanting single dose vials listed with JZ or JW modifier. I am working on finding out if 2 or more vials are used if they are wanting the J code listed more than once with JZ and JW modifiers and corresponding units. I am very confused and working with UHC to get answers. These are part of the NEW Oct 2023 CMS guidelines that came out, it is just not clear on coding when dosing is more than 1 vial of the same drug
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Have you heard anything on this? if multiple vials are used (same strength) do we bill in a separate line with a modifier KP or KQ?
 
princessahe@hotmail.com said:
@monika.daza@hcidtx.com by any chance do you have an update?
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I had a pharmaceutical company reach out where they were told the denials are in error from UHC (I have no proof this is true). Our claims have not adjusted, we are having to move medications around for our UHC patients to where we are using 1 vial dosing. I have sent in claims where I listed the J code multiple time for example a patient received 2 500mg vials of a drug, I listed the J code 2 times with JZ modifier on each, the claim is still under review.
 
We were just told today that UHC was having technical problems and are working on updating the denials. I don’t exactly know what this means, but I’ll let you know what happens with our claims.
 
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