Wiki HUMANA POST RECORD REVIEW

[pswain@aelcs.com]

I am with a laboratory. We have a referring provider ordering G0481 (8-14) drug classes and Humana is denying because post record review they determined the G0481 as not medically necessary, but in their explanation they are telling us the record supports G0480 (1-7) drug classes. Confirmation testing. They are not paying on the G0480, instead denying the G0481 as NMN and pt is not responsible. Can we change the code G0481to G0480 and file a corrected claim based on the carrier's findings and as supported by the medical record? I am afraid that we are going to have to just "eat" the G0481.

 

[MAbilling]

Yes, Humana only covers G0480, you can send a corrected claim to replace G0481 for G0480 and attach the original claim number to the new claim so they don't deny as duplicate. Also Humana may require 59 modifier for G0480 if billed on the same day with other tests.