POST-PAYMENT AUDITS
BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits can range from a basic encounter audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record and medical practice. Post-payment audits are performed after the service(s) is billed to BCBSKS and payments have been received by the provider. BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit. Due to additional time allowed for provider appeals, as outlined in this policy memo, refunds would be applicable after the provider appeals have been exhausted, regardless of the time frame involved. BCBSKS provides education through policy memos, medical policy, newsletters, workshops, direct correspondence, peer consultant medical opinion, and on-site visits.
If medical necessity is not supported by the medical record, BCBSKS will deny as not medically necessary. When BCBSKS requests medical records for an audit and no documentation is received within the 30-day time limit, BCBSKS will deny for no documentation. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.
Post-payment Audit Appeals:
A. First-Level Appeal
Services denied not medically necessary as a part of the post-pay audit process may be appealed in writing within 30 days of notification of the findings. Written notification of disagreement highlighting specific points for reconsideration should be provided with the appeal. The BCBSKS determination will be made within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.
B. Second-Level Appeal
A provider may request a second and final appeal in writing within 30 days of notification of the first-level appeal determination. The second and final appeal determination will be made by a physician or clinical peer within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.
When findings reveal issues, which are presently specified in BCBSKS policy memos, billing guidelines or newsletters relating to content of service, multiple surgery guidelines, and other billing and/or reimbursement guidelines, the terms of this appeal are not available
NON-COVERED SERVICES
Providers are not reimbursed for professional services they provide to an immediate family member (“immediate family member” means the husband or wife, children, parents, brother, sister, or legal guardian of the person who received the service) or themselves as specified in the member contract.
There are several categories of services, procedures, equipment and/or pharmaceuticals that may be considered non-covered services when designated by the member’s contract. These denials are billable to the member. (
Medicare Payments, Reimbursement, Billing Guidelines, Fees Schedules , Eligibility, Deductibles, Allowable, Procedure Codes , Phone Number, Denial, Address, Medicare Appeal, EOB, ICD, Appeal.
Medicare Guideline posts
- Home
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation process - how often provide need to do - FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list

Subscribe to:
Post Comments (Atom)
Top Medicare billing tips
-
CPT CODE and Description CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires thes...
-
Procedure code and description 11400- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion d...
-
URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule Uribel i...
-
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
-
LAPAROSCOPY ; LAPAROSCOPIC SURGERY Procedures and Related CPT and ICD-9 Procedure Codes CPT Code CPT Description ICD -9 ...
-
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
-
Procedure code and description 93224 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage;...
-
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
-
procedure code and description 11042 -Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm ...
-
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 - Private insurance pay upt...

No comments:
Post a Comment