Sorry I am late into the conversation but I also have an open ticket with Medica. I have used occurrence code 25 which it denied. I was told by Medica provider help to use T1030 with a GY modifier. They still rejected it. I called and asked why – they told me it was sent to the wrong department.  So still waiting to see what happens. This has been going on since November 2014 thru the current month services provided.

 

 

Gotta love medical billing!

 

 

Nothing being done wrong that I’m aware of, we are billing T1030, it is Medica Accessibility, so only SNBC or MSC+, and we are only receiving denials when there is Medicare available. We have only very recently been receiving rejections, and they are on Clients who previously we were receiving payment on with no issue (for several years). There is no private insurance or other coverage available, Medica denied because of COB with Medicare coverage, assuming we should be billing Medicare, even though we are billing with the 25 occurrence code. I have an open ticket in with Medica provider service, because we had so many denials at one time.

 

We have quite a few clients on these plans with dual eligibility. I am guessing it is likely a system issue on Medica’s side, and maybe if they specify that the T-code is a non-Medicare code, it will correct itself. It’s been about a month since we had the large number of denials. I haven’t checked in on the claims yet, so I’m hoping maybe the issue has been corrected! I definitely agree, until this, we had pretty much no issue with Medica skilled billing, so I was really surprised by this!

 

If I do find out what was wrong, I can let you know! I am more on research than actual billing or payment processing, so I don’t always know when claims just start processing correctly. I just keep hoping no one asks me to do more follow-up, because that means it is fixed. J

 

 

 

It is likely another issue then. Are you using the correct codes? Also, Medica Prime Solutions is a part B only policy so if you bill to that plan, your wrong and won’t get paid. I really have never had any problems with Medica. Is it an authorization problem? If you ever get a denial, you could maybe shoot the denial code out and see how many other people  are getting that denial code.

 

 

We have been billing with occurrence codes but still receiving denials. But maybe when I call for reprocessing, I can draw their attention to that occurrence code. Those codes work great with MA, but Medica in our case has not seemed to recognize them consistently. Hopefully that has gotten better and I’m just not aware of it yet!

 

 

 

Neither have I. Sometimes the claims get denied anyway and that’s because there is another insurance such as a private insurance plan. However you can use a modifier 24 for those if they will not cover the service. And of course private insurance plans follow Medicare usually so that’s a good guideline to determine who will be the payer and you can massively simplify your billing.

 

 

Yes we use the 25 occurrence code and the date the patient signed the Medicare noncoverage ABN form as the Medicare denial.

 

I have had no problem with Medica paying on these Medica SNBC claims with this information or any type of MA claims.

 

 

 

Awesome! Thanks Tracy! And everyone else!! Very helpful info!

 

 

Ok there is a really simple way to do this. Place a 25 modifier on the claim which says it is not a Medicare covered claim. Put the correct date that the service is not Medicare covered (you need to make sure you have verified it is not Medicare covered) and send it.

 

 

Hi

 

Here are the instructions for a “no-pay” bill to Medicare

 

TOB is 320

Same statement dates as a regular Medicare claim

Condition code 21

Patient Status Code 01

If no Oasis –Use HIPPS code 1AFKS and Treat auth 11AA11AA11AAAAAAAA

Your Charges need to be “non-covered”----When I do this my charges are in both the covered and non-covered fields

Need to include Remarks why services are “non-covered” like “Medica is requiring a denial from Medicare”

 

I have billed several of these and when you get the denial back from Medicare you submit it as an attachment with you claims submission to your payor

 

This info is from CMS

 

 

Hello, when we have a patient who is not homebound, we have no face to face and want to bill Medica MA and Medica turns around asking us for a Medicare denial how do you submit a claim to Medicare for a denial?  We submitted for denial and they paid even though our OASIS was Medicaid.  Is there a code or a flag we put on a Medicare claim letting them know we want a denial?

 

We have a few other Medica MA patients that we did not have this issue with, it’s only this one so we are pretty confused and feel like we have used all options. If anyone knows what I can do I’d sure appreciate it!!

 

____________________

Kimberly Gardner

Homecare Biller / Secretary

Grand Itasca Clinic and Hospital

111 SE 3rd St

Grand Rapids, MN 55744

Ph# 218-999-1055

Fx# 218-999-1052

kim.gardner@granditasca.org

 

Looking Forward to Caring For You