#deniedclaims – KR2 Medical Billing

EmblemHealth NY, NY Providers, Payer Updates

Emblem Health: claims timely filling update- Self Funded Plans (ASO)

Posted on October 7, 2024 by KR2Medical Billing

Keeping up current on any claim timely filing updates is crucial for your business!

Claims that are denied for timely filing can be rarely appealed and get paid. (Certain situations like COB/Natural disaster)

So, I always pay a close attention to any timely filling changes that are reported by the healthcare payers/plans.

Below please note the changes that took place for Self Funded (ASO) type of plans.

Find this type of information useful? Please follow my blog for more healthcare related information.

NYS Medicaid POC Syphilis testing coverage
Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members. Where is this test covered (POS)? physician/nurse practitioner/licensed midwife private office setting What kind of POC is covered and reimbursed? Currently there is only one FDA approved test -Clinical… Read more: NYS Medicaid POC Syphilis testing coverage
NYS Medicaid OBGYN CPT II codes reporting requirement
If you are a provider in NY and accept Managed Medicaid or Fee-for-service Medicaid plan types, then this blog post post is for you! For any DOS (for deliveries on July 1, 2024) and thereafter, the OBGYN providers billing bundled/global OBGYN codes, are also required to bill the following CPT II reporting codes. Global OBGYN… Read more: NYS Medicaid OBGYN CPT II codes reporting requirement
NYS Medicaid: Bariatric Surgery Medical Policy Update
Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you! Non surgical treatment should be attempted: ex. diet and increased exercise. Bariatric Surgery Adult Patient: 18 years old and over Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a… Read more: NYS Medicaid: Bariatric Surgery Medical Policy Update
NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding
Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you! When: this applies for any services done on/and after Jan 1, 2026. Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient… Read more: NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding
Hedis Measure: Controlling Blood Pressure Controlling Blood Pressure
Are you a provider that participates in reporting HEDIS measures? Then this blog post is for you! What is this measure: the measure assesses if adults (18-85) with hypertension have their blood pressure adequately controlled, below 140/90 mm Hg. and below 130/80 Hg. Documentation Requirements: 1. Adults 18-85 with a hypertension diagnosis. 2. At least… Read more: Hedis Measure: Controlling Blood Pressure Controlling Blood Pressure

Insurance

Announcement: NY Empire Plan Claim Submission for 2019 Services -April 29,2020

Posted on April 28, 2020 by KR2Medical Billing

General: Please remember that UnitedHealthCare (claim administrator for NY Empire Plan) has a claim submission policy of 120 days from the DOS (Date of Service). Empire Plan Secondary Claims also have a claim submission policy of 120 days from the date that Medicare or another insurance claim has processed the claim.

For Services performed at the end of year 2019 have to be submitted on April 29,2020

Paper Claims Address: those providers that are unable to submit electronic claims have to send their claims to The Empire Plan, PO Box 1600, Kingston, NY 12402-1600

Reminder: When benefits are denied because of the claim being submitted late, the participating physician or health care professional MAY NOT BILL the patient for the charges on that claim.

Insurance, My services, Payers and CPT reinbursement, Training

Empire Plan(UHC) and CPT code 95004

Posted on November 22, 2017June 7, 2018 by KR2Medical Billing

This is a third installment in my Payers and CPT codes series.

In this installment we will look at the payer Empire Plan (Light Blue card). For this payer UHC is the third party administrator and handles all administrative duties.

Now I am sure you know that when you see a patient with this type of insurance, there is a $20 copay for the office visit. However, not many providers know that there is also another fee for another service, if that services is performed on the same date.

The following will help you to collect the correct amount of patient responsibility from the patient, on the day of services are rendered, and not wait until the claim is processed, which could be 14 or more days; thus increasing your cash flow and reduce your outstanding A/Rs.

In this scenario, you have a new patient coming in to see an allergist for an unspecified allergic reaction:

Code 1: 99204 or 99203 – NEW PATIENT Patient responsibility- $20

Simple.

Ok, now the patient also has not taken any antihistamines in at least the last week and would like to do prick allergy testing , cpt code 2: 95004.

According to UHC, the third party administrator for this plan, 95004- is considered a separate (diagnostice) procedure if performed on the same day, therefore there is also an additional co payment of $20 that is attributed to the patient responsibility.

So, lets review- new patient code 99204 or 99203 w/25 ,a code 95004 for skin testing – patient copay $20 for the office visit and $20 for the prick allergy testing.

Since I already know this in advance, I have a separate form that I give to patients when they arrive to the office, BEFORE performing the procedure.

Giving the patients the option of either doing the prick testing or sending them for blood work (no additional fee when they on that day, if dont in the outside lab)

If you have any other further questions, please feel free to contact me via email or phone, listed on my about me page, or via my LINKEDIN account or my Facebook page.

Until next time!

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