Pediatric office vs Highmark BCBS Anthem BCBS

ssharp

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Covington
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I need some help. Has anyone in the pediatric area had issues with Highmark not paying for the UA and CBC stating that it is not covered per age/gender. Local bcbs plans pay for those. I am confused on what I can do. I have called the home plants and they state is plan specific. We have not notified the patients prior to the visit that it is not a covered service. Where do we stand on billing for this or do we have to write them off.
 
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I know they said it's plan specific, but maybe it's a DX issue. Are you able to give the plan name without making it too specific to the patient?
 

ssharp

Networker
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Covington
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bcbs of Alabama Highmark. I have had one say that it doesn't cover the 81003 or 85025 for Z00.129 or Z00.121
 
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Again, I know they're stating it's "plan specific", but I found some pieces of information here and there and may have stumbled upon something. Are you billing these with or separate from a preventive exam code? Is the provider just ordering the labs and the workup is being done in a lab elsewhere (onsite or offsite)? Are the labs being billed by a provider other than the ordering provider? If you're billing with Z00.121, are you including the codes for the abnormal findings?

As far as balance billing, technically the patient's guardian(s) should know what their plan covers and what it doesn't. They will get an EOB showing the denial as well. So they really should know they're going to be balance billed. Obviously that's not necessarily good billing practices from an outsider's standpoint. However, you need to be careful about writing the charges off when they've been deemed as patient responsibility. There's been a lot of "talk" about that type of thing in relation to the anti-kickback statute - if you do it for one patient, you'd have to do it every patient. I'm not a fan of this because I think there are circumstances where a courtesy adjustment is the right thing to do.
 
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