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Wiki J0129 Orencia Billing to BCBS Medicare Advantage

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Katrinadiperno

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Phoenix, AZ
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We have several patients at our Rheumatology office that receive Orencia. However, we are having difficulty receiving payment for the drug when billing BCBS Medicare Advantage. We bill J0129 with the JA modifier and as of recent, with the JZ modifier attached as well. Most claims were billed with admin code 96413 and then several claim corrections were rebilled with the downcode admin of 96365. The plan continues denying our claims stating it is not Medically Necessary based on LCD or NCD. We render services in Arzona, and currently there is no active LCD on file with Medicare Jurisdiction F. When we explain this to the BCBS local AZ, they state that this is all the information that they can provide us. We have contacted the host plans (Michigan, Illinois, Minnesota) and they are telling us that this denial is not coming from them, but that BCBS of AZ did not price the claims before forwarding. We are trying to work with our BCBS Provider rep to find resolution; however, she isn't of much assistance.

Is anyone else having this issue in AZ or other states? Any guidance would be appreciated.
 
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