Wiki BCBS Denying for Family Planning Office Visits at Health Department

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khartoum1900nile@aol.com

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I work at a Health Department as a part-time biller. Recently, BCBS started denying several patients visits due to the Max benefit being reached. BCBS did pay for the annual and maybe one follow-up visit, but started denying the visits after those two. Patients come here for their Depo shot 4 times a year, once usually with the Annual. So we get paid maybe two visits and the other two will be denied. Most of the time, patients don't have Medicaid as secondary to cover what BCBS denies (we only bill Medicaid for Birth Control Pills and not the Depo). This is just something new that has started with BCBS and it's not just one or two patients, but at least 20 or more that have now started to deny. In the previous years, this has never happened and now we have to start billing the patient if they fall in a fee bracket and don't have Medicaid.

Is this something new with BCBS?
 
What is your denial reason? What procedure and diagnosis codes are you submitting on the claims that are being denied by BCBS? IT is helpful when posting these types of questions to know what the denial reason is and the claim information.

You say you've been billing these services without issue previously, but has absolutely anything changed in your clinic's coding & billing processes? It doesn't sound like there has not been any changes but sometimes the smallest things get changed that are seemingly unrelated that actually could impact the claims you are sending to BCBS.

That said, have you checked your BCBS resources, newsletters, provider alerts, provider portal updates, to see if they've posted a change to their policies for reimbursing these services? BCBS also could've made a change to the configuration of their claims system that is causing this to happen, and it may be mistake.

The first step is to figure out what their rationale for denying the charge is and so that you can figure out what your next steps are for getting your claims processed correctly.
 
Procedure code is usually a 99213 or 99214 and the Diagnosis code is Z30.9 for the most part. I don't see the actual claims being entered, I just follow-up after they have bee either paid or denied by the Insurance.
 
So, you do not see copies of the remits from BCBS showing how the claims are processed? If so, you need whoever is reviewing those documents to provide you the information about what the denial reason is on remit that BCBS is sending your clinic so we can try and help you figure out what is going on and what we can do to help you as a community.
 
To be clear you are referring to BCBS of Alabama, correct? I'm making that assumption based on your location being listed as Alabama. If it isn't BCBS of Al, which BCBS is it giving you problems?

Also, since the services for providing a depo injection are separately billable from an office visit/E&M, they aren't obligated to cover the visits per the following snip in BCBS of AL's Preventive Care Services under Healthcare Reform policy # MP-447. This policy was last reviewed in January 2023.
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Bear in mind, included in the insurance companies' ability to apply cost-sharing to the office visit, they can also impose other limitations, such as visit maximums or frequencies (see the section highlighted in purple), because the mandate to cover the preventive service is applicable to the procedure codes which represent the mandated covered preventive services.

In the header of this document there is a link to BCBS of AL's preventive care services coding guidelines document title Healthcare Reform, see link. In the 2nd table titled "Women's Preventive Screenings" There are a copy of lines that your office visits were being reimbursed under before these sudden denials. I included the line related to Well Woman Preventive Office Visits because you mentioned in your original post that one of the 4 annual injections are given during their annual visit, there are 3 separate lines under this benefit with the benefit listed based on the coding and each has its own frequency limitation.
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I don't see anywhere in these coding guidelines coverage listed for an E&M 99213/99214 w/DX Z30.9, and it looks like this document was updated in 10/23 based on the teeny tiny annotation "LR 10/23"in the lower right-hand corner of the document. This probably stands for "last reviewed 10/23". I say this as someone who works for a "Blue" plan myself and my familiarity with some of the strange codes included in documents that seem to mean nothing to the users.

After all of this information being tossed at you in my post, I'm going recommend you contact BCBS of AL to find out why they are suddenly denying these visits, did they have a change in policy? Did they have a system upgrade and maybe there was an issue with the upgrade that is mistakenly causing these services to deny. You'll only know whether you can get reimbursed by BCBS of AL for these services by calling them and seeing why they are denying and is there anything you can do to get them reimbursed.

Good luck! ☮️
 

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