Insurance Requiring Diagnostic Code for Preventive Screenings

clocke

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Hi all,
I'm new to the forums and not a coder, but I am tasked with helping our patients resolve billing issues with our lab vendor (Quest).

A patient with Unicare is being denied coverage of three preventive lab screenings: HIV screen, HepB screen and HepC screen.

The patient's insurance lists all three of those screenings under their Preventive Care Schedule, but they insist that they will only cover the screenings with a medical diagnosis code (assuming that means a symptom based code).

They tell me they will not cover any of the screenings with the various Z-codes we have tried to use.

The patient is furious ($600) and I am at a loss -- am I missing something here?

Anyone have any experience with trying to bill for similar tests? I don't understand why they would require a diagnostic code for a test that is listed under their covered Preventive screenings.

Any thoughts or guidance is appreciated!
Cyndi
 

CodingKing

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I wonder if this is one of those grandfathered plans or Medicare based plans that do not cover preventive care? If that's the case there is nothing that can be done as it would be against the law to make up a diagnosis code in order to push a claim through for payment.
 

ttspoon

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Preventative Service with a diagnosis

In my experience, when the plan lists a service as preventative but requires a non-screening dx it is usually only covered for high-risk patients. The plan HAS to provide you with the basis for their decision, whether it be to the member's policy booklet or their claims manual. I am usually directed to a webpage for such information.
T.Spoon, CPC
Billing&Coding Manager 15yrs
 
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