Insurance question

[mommywri]

Hi,
Am still trying to get paid for a batch of cuvettes but my insurance company doesn't like the diagnosis code that my doctor put on the certificate of necessity (I think) We have gotten 4 requests for a diagnosis code which I have responded to 2 times by sending a copy of the certificate. My doctor has faxed over more information but I think something is hung up. Would anyone know the correct ICD-9 code for mechanical heart valve? Is there any other ICD-9 code having to do with a mechanical valve as a reason for having a protime monitor? (It has now been almost 4 months since we submitted the claim) Thanks for any advice you can give.

Martha (mom to Christina, Truncus Arteriosus, pace maker, aortic(truncal) valve replacement (St. Jude) 10/02.

 

[Ross]

424.1 Disease of heart valve, aortic, NOS
394.9 Disease of heart valve, mitral, unspecified
424.3 Disease of heart valve, pulmonary
424.2 Disease of heart valve, tricuspid

That's all I can find.

 

[mommywri]

Thanks Ross,
That was very quick. I think I'll suggest these to the cardiologist. He didn't use a number for the mechanical valve so that may have caused some problems.

--Martha

 

[Ross]

For what it's worth, mine uses 424.1 for me. I didn't see any coding related to mechanical valves only diseased valves.

 

[Michele]

The code for mechanical heart valve is V43.3. Let me know if I can help you further. Thanks.

 

[mommywri]

A big thank you Ross and Michele. I am going to call our case manager and give her the ICD-9 codes you recommended. QAS has agreed to submit claims for cuvettes in the future as well so a big thank you to QAS too!

--Martha (mom to Christina mechanical aortic(truncal valve) replacement 10/02)

 

[mommywri]

Insurance claim form

Insurance claim form

Well,
Even with the new information, we just got a request from our insurance company for a procedure code and and the provider name, address, and TIN #. I have sent this to QAS in the hopes that they can help. I know that the provider name and address are on the invoice but does anyone know what a TIN# is? I can't find it anywhere on any invoice.
My call to Cigna's case manager to see if she could help was not helpful--basically she just blamed the equipment provider for not providing the correct information and said that if the claim was denied because of insufficient information again we could resubmit the claim again and see if that would work.
No one at Cigna from the case manager, customer service reps, or customer service rep supervisors is willing to tell me what it takes to file a clean claim (what information and what TOS, POS numbers Cigna uses -- I think they are not the same as Medicare's because I have a copy of a claim form submitted on my behalf and the doctor's office code is not 11 on this.
Thanks to all for listening to me vent. If you have any advice I'd appreciate hearing it.

Martha (mom to Christina aortic (truncal) mechanical valve 10/02)

 

[Ross]

Martha I think it might be the Tax Identification Number they're after. I think you should call Michele personally and have her take care of it for you. She is willing to help.

 

[LUVMyBirman]

Just curious if anyone receives reimbursement from Blue Cross? We may be changing polices again. Hopefully this time my supplies will be covered

 

[Rain]

procedure code

procedure code

Martha,

A couple of times my insurance company has denied payment. When I called them I found out it was because QAS bills it as ?durable medical equipment?. I had to talk to the insurance people two or three times and have QAS resubmit the claim. Once I convinced them that the cuvettes were ?LAB? work they paid it with out any problem.

Could that be what the problem is with the ?procedure code? ?

Gina, Blue Cross is who I had insurance with when I got my monitor. Hopefully you won't have any problems with them.

 

[Gisele]

Gina & Martha

Gina & Martha

I have BCBS of MA. They did make an exception through the grieveance department and purchase my machine at 100%. They also pay for the supplies. About one year ago they notified me that this is now a covered service through my plan. Do not forward any invoices as DME (durable medical equipment) as that is not normally covered at 100%. DME is covered at 80% for my plan. I also learned that when BCBS plugs in QAS it automatically comes up as a durable medical equipment provider. So a notation that you have not purchased DME would probably help.

You have a CoaguCheck, right?

I find it easier to submit with a cover letter explaning what code to use and I refer to my previous claims where I had 100% coverage.

Naturally, how your submission is handled depends on your policy and what state is providing the coverage.

Good luck and let me know if I can be of any help.

Martha, TIN is tax identification number. Ross was right

Gisele

 

[mommywri]

Thanks so much

Thanks so much

Dear Everybody,
Thanks so much for your advice. I learn so much from this forum. We were only reimbursed 80% for the Protime monitor and cuvettes. This year it is less because our coverage for non-participating providers is only 70%. If you bill cuvettes under "lab", what code do you use? Since we have billed under E1399 this comes up as miscellaneous supplies and gets reimbursed at 70% because it is medical equipment. Also, if the insurance company doesn't presently have a participating provider that provides a protime machine, can you grieve for them to pay what they would pay a participating provider? Thanks again, you are terrific.

Martha (mom to Christina, Aortic (truncal) mechanical valve, pacemaker 3 open heart surgeries)