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Over the top BCBS Request

  1. #1
    Arrow Over the top BCBS Request
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    A parent presents a child to an ENT for epitaxis.
    BCBS has placed the clm on hold pending further information.
    They are requesting the HX of the nose bleed, a physical and all of the childs medical records.
    Has anyone encountered this?
    I questioned BC as to what they will do should it be discovered that the girl was picking her nose and it started to bleed.
    They would not answer me. Parents of nose pickers beware. BCBS is preparing to mark your children with pre-existing condition tags.

    Seriously though, has anyone encountered a request as such? How was it resolved?

  2. Default
    Quote Originally Posted by Oceanlivin View Post
    A parent presents a child to an ENT for epitaxis.
    BCBS has placed the clm on hold pending further information.
    They are requesting the HX of the nose bleed, a physical and all of the childs medical records.
    Has anyone encountered this?
    I questioned BC as to what they will do should it be discovered that the girl was picking her nose and it started to bleed.
    They would not answer me. Parents of nose pickers beware. BCBS is preparing to mark your children with pre-existing condition tags.

    Seriously though, has anyone encountered a request as such? How was it resolved?
    I see why this all sounds silly and a complete waste of time, not to mention holding up payment to your practice. But since our practices only see one small part of our patient's claims...maybe there is more to the story than we can see. WHAT IF this patient (child) has a history of odd ER visits...or this isn't the first ENT for nosebleeds this patient has visited...or there is a history of suspicious medical issues that makes the BC plan wonder what in the world is going on with this child? Not usually an alarmist...but I would give them what they ask for since it may be a safety concern for the child.
    Jenna

  3. #3
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    I see similiar denials from BCBS when using asthma dx codes. We just fill out the form they usually send & then attach records & it usually gets released for payment.
    I recall calling BCBS awhile back when I'd first see the requests & the explaination was there are certain dx codes that get flagged for review...asthma happens to be one of them...just a thought but the dx you are using might also be too? Maybe give them a call to get a better explaination....
    Last edited by hopepg; 11-09-2010 at 03:59 PM.

  4. #4
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    I also think it's possible that some employer groups through Anthem/BCBS may have these requests automatically sent out regardless of the claim submitted. We had submitted a claim for a patient's emergency appendectomy and still received a form requesting information about the possibility of this being a pre-existing condition. We filled out the form and returned it simply to prevent holding the claim from processing. The patient was also extremely upset when he received his copy of their request. I suggested to him that he call his carrier as well as his employer's HR department to complain about the issue.

  5. #5
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    I have not seen one in a long time.
    Now I have gotten three more in this past week.
    I suppose they may be conducting some sort of internal audit.
    I'll take a look at the dx's and see if there is anything in common.

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