Wiki Am I wrong???

[goldenmelinda]

We are an outpatient mental health facility. T1017 (Targeted Case Management) and H0038 (Peer Support) are not billable to Medicare, right? These codes have an E1 status:

"Both E1 and E2 are not paid by Medicare when submitted on outpatient claims (any outpatient bill type).

E1 is used for items and services that are:

-Not covered by any Medicare outpatient benefit category
-Statutorily excluded by Medicare
-Not reasonable and necessary"

I am asking because we have a client who has been conversing with Medicare customer service, and Medicare is telling the client that I need to submit claims to Medicare for these services. I did create a claim with a GY modifier just to see if it would go through (just for the purpose of receiving a denial) and the clearinghouse rejected the claim due to the HCPCS code. I called our MAC and the MAC said T1017 and H0038 are not even in their system so the claims will not go through. Even with this information, Medicare keeps telling the client that we need to submit these claims to Medicare. When I called the MAC to see why Medicare customer service would be telling the client this, the MAC just told me "I don't know." I am about to pull my hair out. This is causing a lot of stress for the client and it is affecting the client's mental health. I want to resolve this, as it has been going on for months.

So basically what I need to know is, is there any way to get the T1017 and H0038 claims through the clearinghouse to get a denial?

TIA!

 

[Chelle-Lynn]

The answer would be no. If these are codes that are not covered by Medicare and not even in their system to deny, then claim will continue to reject at the point of the submission.

Moving forward, in regards to handling this with your client. A couple of options are available:

* Has the client provided you with a reference number and contact name of who she is speaking with at Medicare? If so, you should be able to call in and either speak with that representative or have the issue bumped to a level 2 representative for additional clarification on what they are advising the patient.

* Possibly when you are speaking with Medicare you could conference the patient into the call so that you are both hearing the same information from Medicare at the same time.

* Does the patient have a secondary carrier? Often times the secondary carrier will process the claim without the Medicare EOB when the service is not billable. We have had luck with this option on multiple occasions.

It can be very confusing for the clients when speaking with Medicare. Even as trained staff, we often time have to call Medicare multiple times to get a clear answer....I cannot imagine being the patient with no insurance or billing background trying to sort though the murky waters of Medicare rules.

 

[goldenmelinda]

The answer would be no. If these are codes that are not covered by Medicare and not even in their system to deny, then claim will continue to reject at the point of the submission.

Moving forward, in regards to handling this with your client. A couple of options are available:

* Has the client provided you with a reference number and contact name of who she is speaking with at Medicare? If so, you should be able to call in and either speak with that representative or have the issue bumped to a level 2 representative for additional clarification on what they are advising the patient.

* Possibly when you are speaking with Medicare you could conference the patient into the call so that you are both hearing the same information from Medicare at the same time.

* Does the patient have a secondary carrier? Often times the secondary carrier will process the claim without the Medicare EOB when the service is not billable. We have had luck with this option on multiple occasions.

It can be very confusing for the clients when speaking with Medicare. Even as trained staff, we often time have to call Medicare multiple times to get a clear answer....I cannot imagine being the patient with no insurance or billing background trying to sort though the murky waters of Medicare rules.

Thank you very much for your reply and your suggestions. I agree, Medicare can be very confusing and unclear at times for anyone. I will try to get the client to provide me with a reference number and contact name of the Medicare rep and see where that gets me. I have suggested a conference call to the case manager before, but it hasn't been arranged which I imagine is due to lack of cooperation from the client . The client does have secondary insurance, but the secondary rep I spoke with confirmed the client's benefit plan does not cover these services. Thanks again!