Wiki Medicare Advantage and annual physical billing- HELP!!

[lbutler]

We are having a terrible time trying to get Braven Health (Horizon BCBS) and assorted other Medicare Advantage plans to pay for an annual physical. They are supposed to cover both the AWV and a physical each year for their members. Their standard denial is that they follow Medicare guidelines and since 99397 is not covered by Medicare they won't pay it either. Does anyone have any advise on how to get them paid other than making multiple phones calls and appeals?

 

[kristenwilliams]

Our practice bills Medicare Advantage plans for both without any issues. The annual physical (99397) should have the Z00.00 as the primary dx but when the patient comes back for the annual wellness, the Z00.00 should not be on the claim at all.

 

[thomas7331]

We are having a terrible time trying to get Braven Health (Horizon BCBS) and assorted other Medicare Advantage plans to pay for an annual physical. They are supposed to cover both the AWV and a physical each year for their members. Their standard denial is that they follow Medicare guidelines and since 99397 is not covered by Medicare they won't pay it either. Does anyone have any advise on how to get them paid other than making multiple phones calls and appeals?

What's your source for saying that they are supposed to cover this? Many MA plans do cover an annual physical, but I'm not aware that it's a requirement for all of them to cover it.

Have you looked at the payer policies or the patients' plan documents to verify if in fact this is a benefit, and if so, if they have any guidelines on how they want it to be billed? But if they in fact it's not a benefit, then there's nothing you can do - no amount of phone calls or appeals is going to override the benefits.