Denial Inquiry

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Location
San Juan, PHI
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AETNA denied a claim as 99205 inclusive to the provider's specialty. I called and they stated that the provider is registered as a radiologist however we are billing him as Internal Med. Could you please explain more on the denial

Thank you
 

thomas7331

True Blue
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A radiologist is a physician and it is within the scope of the training and license to perform evaluation and management services for patients. Since a radiologist is a specialist, it makes no sense to me that they're telling you that you're 'billing him as Interned Med' - that is nonsense and I think they've given you incorrect information. E/M codes are not limited to internal medicine providers.

I don't know why Aetna would deny this unless they have a policy that limits payment for certain provider types, or unless the radiologist has a contract with Aetna where they have agreed not to bill for E/M services. Or it could just be that they made an error. If it were my claim, I would push Aetna for a more clear explanation for why the radiologist cannot be paid for this. If a payer denies a claim, they should have policy or contract language to support it and they should be able to provide this to you.
 

trarut

True Blue
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594
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Columbus, OH
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Aetna is weird. It could be the provider is set up in your billing system with the wrong taxonomy code and they're using it as an excuse not to pay. While the taxonomy is not on the hard copy claim form, I believe - in our system anyway - the information goes out on the electronic claim.
 
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