I have been told by the pediatric manager that when a child comes in for a wellness check (where they usually receive vaccines) that Medicaid or CMO insurance is billed as PRIMARY and the commercial insurance is SECONDARY. I don’t believe this to be true, does anyone know if there is an exception to the rule that "medicaid is always the payer of last resort" and where can I find this if it exists. She wants to bill medicaid as primary when they come in for wellness/vfc vaccines and bill commercial when it’s a sick visit.
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Tag Archives: COMMERCIAL
Commercial Insurance and Medicaid
I have been told by the pediatric manager that when a child comes in for a wellness check (where they usually receive vaccines) that Medicaid or CMO insurance is billed as PRIMARY and the commercial insurance is SECONDARY. I don’t believe this to be true, does anyone know if there is an exception to the rule that "medicaid is always the payer of last resort" and where can I find this if it exists. She wants to bill medicaid as primary when they come in for wellness/vfc vaccines and bill commercial when it’s a sick visit.
Commercial Insurance and Medicaid HMO in Florida
I hope you can assist me with an issue we have gone back and forth with in our office. If a patient has a commercial policy & Medicaid managed care (Sunshine, Staywell, Prestige) policy as secondary, is the patient responsible for the co-pay & or deductible?
Example 1: We submit a claim to BCBS for $ 150. They apply the allowable of $ 100 to patient deductible, our contractual adj. is $ 50. We submit a secondary claim to Medicaid managed care plan. The Medicaid MMA pays their allowable $ 50. What happens to the other $ 50? Is it adjusted off as contractual adj under secondary or is it patient responsibility?
Example 2: We submit a claim to BCBS $ 150. They allow $ 100, $ 50 payment and $ 50 co-pay, our contractual adj. is the $ 50. We bill the Medicaid product $ 50 patient responsibility. The Medicaid MMA does not pay anything because primary paid over Medicaid allowable. Can we bill the patient for that $ 50 co pay balance.
What is “MA” and/or “ACA” Commercial coding?
What is "MA" and/or "ACA" Commercial coding?
Ive seen listings in jobs that ask if you have this/these experience.
Anyone know what they mean or stand for?
Ive seen listings in jobs that ask if you have this/these experience.
Anyone know what they mean or stand for?
Risk Adjustment Calculations in the Commercial Line of Business
Small group and individual markets have unique strategic opportunities for coding and operational processes. Risk adjustment is predictive modeling that assesses members’ risk for incurring medical expenses above or below the average during a defined time. Demographics and health status are used to determine health plan payments, which also can assist with care management needs. […]
AAPC Knowledge Center
Hepatitis C Screening CPT and DX for Commercial Ins
Can anybody give me some insight on what hepatitis C screening CPT codes and diagnosis codes that can be used for commercial payers. This is for the one-time screening for patients born between years 1945 and 1965.
I know UHC will cover diagnosis Z11.59, but other payers such as Aetna do not pay for that diagnosis…
Thanks!
Take Commercial Appeals to a Higher Level
Claim denials cost the medical industry over $ 1 million, annually. How much of that comes from your practice? You spend time interpreting sometimes confusing health plan benefits and coverages and wordy coding guidelines. You go through time-consuming prior authorization processes. And you sign up for a payer’s electronic funds transfer and post claims per their […]
AAPC Knowledge Center
99152 Denials by Commercial Payors on GI procedures
I have been receiving denials from several commercial payors on 99152 when billing with GI Endoscopic procedures. Payors are stating it’s bundled with primary procedure, but I was of the understanding the MCS part of the procedure was pulled out of the primary procedure value as of January 1, 2017. Has anyone else been experiencing denials on 99152 with GI procedures? If so, have you had an luck with resolving?
Aetna commercial and Aetna Medicare
With Aetna and Aetna Medicare, is anyone getting increased reimbursement with use of the -22 modifier? (with proper documentation)
commercial primary, Medicare secondary
If a person has Commercial BCBS as primary insurance, and Medicare as a secondary insurance. Can a surgeon bill a consult code?