Wiki Can an insurance request this info.....

[tmarugg]

Cigna is denying our claim for assistant surgeon charges. "To determine benefits, we need the health care professional to submit the name, degree/title of the individual health care professional who actually rendered the services."

The claim does have her individual NPI in box 24J. When I called customer service I was advised that they required a letter stating the needed information.

My argument is...isn't this why we have NPI's????? We have a contract with Cigna, so in that contract they have her information in their system. Can an insurance actually require separate documentation of a performing provider?

Thanks in advance for any advice. This is just so frustrating.

 

[CodingKing]

Maybe its poor wording and they need the name of the primary surgeon?

 

[tmarugg]

Maybe its poor wording and they need the name of the primary surgeon?

The surgeon's claim has already processed & paid. I was just a tad bit frustrated when I posted my original question

But thank you for responding.

 

[kivbar16]

Most payers require the name and credentials of the assistant surgeon be stated in the op note; they are not going to review a contract to determine this information. Also, many expect the primary provider to state the necessity of the assistant, i.e. what he/she did that was imperative to the procedure.

 

[karlene.dittrich]

I also bill for a surgical assistant. This is a merely a new delay and denial tactic for Cigna. As a company that also provides specialized appeal and claims recovery services, I suspect there is a lot more going on in the background that you may not realize. Among other rights providers have, there are state laws that support non-compliance on Cigna's part in requesting information they already have access to. Utilize your rights and Appeal the unsupported denial.

Karlene Dittrich, CBCS, CPC, CPMA
Insurance Reimbursement and ERISA Appeal Specialist/Consultant