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We received notification from Security Health Plan that they made a change in how they process claims for obstructive sleep apnea, so that now you can only bill the appliance code and no other treatment codes. Therefore you should adjust the cost of the appliance to include the full cost of treatment. However, all other insurances as far as we know, you still bill out the consult / scan codes separately. The issue we are wondering about now is we have a patient who has two medical insurances. The first insurance is anthem blue cross blue shield and the secondary is Security Health Plan. In order for it to go through both insurances, would it be best to bill to the primary as we would regularly or should we be billing it all under the one code as the secondary is going to want it? So that the primary EOB will match the claim when we send it to the secondary?
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Hi jbublik! Great question. Yes many insurers have started considering E0486 as a bundled or global fee to include all services to fabricate the appliance through 90 days of follow up care, especially since Medicare clarified this a few years ago, private insurers will usually follow suit with Medicare over a few years following. Here is a link to a JM Part B announcement that clarifies correct coding for E0486: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~Browse%20by%20Topic~DMEPOS~96ESLW3556?openHope this helps, have a great day!
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Rank: Member
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Just want to make sure we are doing this correctly then. Our patient has Anthem insurance for their primary medical insurance but then Security for their secondary medical insurance. The Security insurance is the one that will be paying the most towards the appliance. Should we bill to both Anthem and Security as the bundled appliance with the full cost of treatment, or should we be billing to Anthem with the separated out line items? As we want to make sure that when we send the information from the primary Anthem to the secondary insurance Security, that we won't have any issues.
Thanks!
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Hi jbublik!
Yes if it were me, that is how I would do it :)
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Sounds good! Thank you for you help! :)
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Hi, I am trying to take this on in my own hands to help a co-worker out. If I were to submit a claim for sleep apnea, what forms do I send in to the insurance company.. From what I remember when I did this a year or so ago I submitted the claim form, the sleep study, the signed out of network referral form, the tx/medical necessity form, and the signed affadavit of intolerance form. Is this correct?
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi Brittany!
Great question. Yes what you listed will normally do the trick! Some medical insurers will have different criteria's for coverage. If you would like to let me know the name of the insurer, I can provide you with a link to their medical coverage policy to make sure you have everything they are looking for.
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