ajvanekeren
New
Are other providers having an issue with Molina underpayments in any state? We have had claims underpay 99214 as if it was a 99213, and when we asked Molina about it, we were referred to this 2020 bulletin: https://www.molinahealthcare.com/~/.../2020-07_Provider_Bulletin_final_for_Comm.pdf
On August 1, 2020, Molina will be implementing a program to evaluate and review high-level Evaluation and Management (E/M) services for practitioners that appear to have been incorrectly coded based upon diagnostic information that appears on the claim and peer comparison. The following are example remittance messages which may be included on, but are not limited to, future E/M claims processed
• Line [X] Service Code ‘99204, 99205, 99215, 99214’ visit level lowered to ’99203, 99204, 99213, 99214’.
• This claim line was processed using a code that more accuratelyrepresents the treatment received.
• The information submitted on the claim does not support the codeoriginally billed. The provider has been reimbursed using the level[insert level] Evaluation and Management code which more appropriately supports the information submitted on the claim.
• Payer deems the information submitted does not support this level of service.
• Alert: Payment based on an appropriate level of care.
If you disagree with Molina’s findings after this review, you have the rightto appeal the decision. Please follow the standard claim reconsideration process indicated in your Provider Manual.
Why not deny for medical records if payer needs supporting info to reimburse that level of service? I have asked for more information and justification for this policy, and I am waiting on a response. The only reason we found it is because our claims management system has rules set up to find underpaid claims. Otherwise this would not have been detected as our paid claims rarely get review. We process tens of thousands of claims a month.
If you've had this happen, please let me know!
On August 1, 2020, Molina will be implementing a program to evaluate and review high-level Evaluation and Management (E/M) services for practitioners that appear to have been incorrectly coded based upon diagnostic information that appears on the claim and peer comparison. The following are example remittance messages which may be included on, but are not limited to, future E/M claims processed
• Line [X] Service Code ‘99204, 99205, 99215, 99214’ visit level lowered to ’99203, 99204, 99213, 99214’.
• This claim line was processed using a code that more accuratelyrepresents the treatment received.
• The information submitted on the claim does not support the codeoriginally billed. The provider has been reimbursed using the level[insert level] Evaluation and Management code which more appropriately supports the information submitted on the claim.
• Payer deems the information submitted does not support this level of service.
• Alert: Payment based on an appropriate level of care.
If you disagree with Molina’s findings after this review, you have the rightto appeal the decision. Please follow the standard claim reconsideration process indicated in your Provider Manual.
Why not deny for medical records if payer needs supporting info to reimburse that level of service? I have asked for more information and justification for this policy, and I am waiting on a response. The only reason we found it is because our claims management system has rules set up to find underpaid claims. Otherwise this would not have been detected as our paid claims rarely get review. We process tens of thousands of claims a month.
If you've had this happen, please let me know!