Wiki HMSA QUEST denies all CCM Codes

[claire@alohavein.com]

Claims under HMSA Quest with CPT codes 99490 and 99439 have been denied, despite these codes being listed in both the Medicaid Fee Schedule and the HMSA Quest Physician Fee Schedules. Other Medicaid contracted payers, such as Alohacare Quest, Ohana Quest, and UHC Quest, reimburse these codes, but HMSA Quest denies them with the denial code 607. Even though there are no E/M codes or other procedures on the same date of service (DOS) for these Chronic Care Management (CCM) claims, and despite resending them with notes indicating their payability, HMSA Quest maintains their denial. The representative could not explain why these codes are listed in the fee schedules if they are to be denied, stating that only the claims department has the final decision. The inquirer believes that contracted Medicaid payers must adhere to the Medicaid Physician Fee Schedule. Your assistance would be much appreciated.

 

[TThivierge]

Hi Claire
Id like to try and help. First read pages 50 and 38 in CPT manual yr 2024. Page 30 states CPT 99439 out of sequence use CPT 99480-99483.It also depends the pt. must have 2chronic conditions , or cognitive impairment , or near death and written plan of care. see pg 50-51. Remark code denial 607 indicates that the service was provided for a condition (s) that is not eligible for compensation or payment under the patient's current insurance plan or coverage guidelines.
I hope this data helps you
Lady T