payor rules/regulations


True Blue
Best answers
As coders we all have a lot of rules to follow.

Where can I find the rules/regulations that commercial ins. comp have to follow.

We are increasingly getting weird answers/denials from ins. comp. We received 2 separate denials for the same claim within a week of each other and they each said something different....when we called to ask about it...we did not get an answer...they just repeat themsevles "its not covered"

I have patients telling me they called their ins. comp. with codes to get an out of pocket estimate...and their ins. comp. is telling them that they cannot give estimate because the pricing is set by the is everyone telling their patients to call the IPA and network to get their estimates??

I am feeling very helpless trying to help my patients.

We have submitted complaints to the ins. commish..... but I dont know if I should be sending the large amount of issues we are having.

Any direction would be greatly appreciated:(


True Blue
Hartford, CT
Best answers
First check the insurance company websites. LIke Medicare they have policies and procedures, they don't call them LCDs or NCDs but they do have them. The websites should have reimbursement policies and utilization guidelines (though not for every code). If you can'tfind anything there then contact your provider rep and requst them (don't bother calling customer service, go right to the provider rep). You can also check your state insurance guidelines to see if there are any mandatory coverge guidelines.

As far as the patients calling for estimated expenses, most IPAs negogiate rates witht the insurance companies, but each party is privy to the information so maybe the patients should ask to speak to somene higher that the reps. If they don't get anywhere with that they should be encouraged to contact the state insurance commissioner and complain.

Hopefully this will help a little bit.
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