Wiki Humana denial of office visit


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I had a patient who came in with a Humana medicare plan. She is a regular patient. The Dr. saw her and gave her a Iron Dextran injection.

The injection (96372) was paid as well as the iron (J1750).
The offfice visit was not paid with denial code PL-50.

PL-50: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

PR : Patient Responsibility

I sent in a claim reconsideration which they still upheld there decision. I than submitted a teir 2 claim dispute to C2C.

The dismissed the dispute with reason: The documentation submitted with your dispute reflects that the claim at issue were for other than a non contracted/deemed provider.

I think that means that since we are a contrated Humana provider we can't bill an office visit when we decide to give an injection the same day?

The claim was coded correctly, 99214(25) , 96372 , J1750.

Anyone seen this one before. We give a lot of injections and never seen this before. Its happened on a couple claims from Humana.:mad: