Billing Humana question
Brittany Stresing, CPO
Description
Collection
Title:
Billing Humana question
Creator:
Brittany Stresing, CPO
Date:
12/28/2021
Text:
Good morning everyone!
Quick question regarding Humana denying items and then we cannot bill patient. We are curious if others have had same issue and what they’ve done.
We have a few items we at times provide that are non-covered by Medicare. We submit the charge to Humana in the same exact format as what We submit to Medicare. However, Humana continually denies them stating that we are coding them incorrectly. Because of the way they deny it (CO4), We aren’t allowed to bill the patient.
This is what Is submitted:
L3100 RT or LT, GY POS 12
L3260 RT or LT, GY POS 12
L3000 RT, LT, GY POS 12 (billed on individual lines)
The diagnosis codes are always consistent with LT or RT.
In the case of L3260, they even told us that We needed to code it as a Diabetic Shoe because the patient was a diabetic, and no matter how much we explained and gave them documentation on it, they did not understand that they were asking me to commit fraud by billing something we did not dispense.
We have appealed these and requested them to correct their denial to PR96, which is what Medicare uses. Weve provided the Medicare LCD and highlighted that it is statutorily excluded. We've them copies of the L3260 brochures that detail exactly what it is, what its used for and the recommended code from the manufacturer. I have even sent them them copies of Medicare remits showing them how they deny it.
Weve have tried all kinds of billing scenarios: no modifiers, GY only, RT or LT only, putting the GY first, putting RT or LT first. Nothing works.
Has anyone else had this issue with the GY modifier and Humana or how are you billing and getting reimbursed or proper denial?
Your help is appreciated! Happy new year everyone!
Brittany Stresing, CPO FAAOP
Quick question regarding Humana denying items and then we cannot bill patient. We are curious if others have had same issue and what they’ve done.
We have a few items we at times provide that are non-covered by Medicare. We submit the charge to Humana in the same exact format as what We submit to Medicare. However, Humana continually denies them stating that we are coding them incorrectly. Because of the way they deny it (CO4), We aren’t allowed to bill the patient.
This is what Is submitted:
L3100 RT or LT, GY POS 12
L3260 RT or LT, GY POS 12
L3000 RT, LT, GY POS 12 (billed on individual lines)
The diagnosis codes are always consistent with LT or RT.
In the case of L3260, they even told us that We needed to code it as a Diabetic Shoe because the patient was a diabetic, and no matter how much we explained and gave them documentation on it, they did not understand that they were asking me to commit fraud by billing something we did not dispense.
We have appealed these and requested them to correct their denial to PR96, which is what Medicare uses. Weve provided the Medicare LCD and highlighted that it is statutorily excluded. We've them copies of the L3260 brochures that detail exactly what it is, what its used for and the recommended code from the manufacturer. I have even sent them them copies of Medicare remits showing them how they deny it.
Weve have tried all kinds of billing scenarios: no modifiers, GY only, RT or LT only, putting the GY first, putting RT or LT first. Nothing works.
Has anyone else had this issue with the GY modifier and Humana or how are you billing and getting reimbursed or proper denial?
Your help is appreciated! Happy new year everyone!
Brittany Stresing, CPO FAAOP
Citation
Brittany Stresing, CPO, “Billing Humana question,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255783.
