Wiki Covering Provider Denial

[grivera]

Hi,

I was recently denied payment by a Medicaid Managed Care insurance company in NYC because the covering physician, although in the same practice did not have the same Tax ID# as the primary care physician on the patients card. The insurance company clearly stated that that was the reason they denied the claim. We were recently acquired by another Medical System and we're slowly transitioning to their credentialing system with their Tax ID#. When I checked with the billing director for my institution she said that the insurance company was wrong and that we had to get away from that sort of thinking. Has anyone had an experience like that? The insurance company said the only way to avoid a denial is for the patient to change the PCP on her card to the covering physician which I have advised the patient to do so.

thanks!

 

[ladondavis]

The insurance denial was correct. Medicaid in any state that I am aware of will deny a claim if treated by another physician other than the PCP, even in the same office. If the patient has a Medicaid Managed Care plan in which they are assigned a PCP, they can only see that PCP. The only exception is an emergency room visit.

 

[grivera]

Thank you so much for clarifying!!