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I've had a few insurance companies state that their allowable is set at ___% of Medicare's rate. I know that the rate for E0486 is not published in the Medicare fee schedule look-up tool. Is there any way to know what the Medicare rate is for E0486, or to know if our charge for the oral appliance is within the Medicare allowable? We are not a Medicare provider and are in Jurisdiction B. I just want to provide our patients with the best possible estimate. Edited by user Wednesday, March 21, 2018 2:27:45 PM(UTC)
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Hi Guest!
Yes, luckily between our software clients and our medical billing service clients, we do know that the allowed amount for E0486 in Medicare DME Jurisdiction B is approx $1300.
Hope this helps!
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Rank: Guest
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Rank: Guest
Joined: 9/8/2012(UTC)
Posts: 17,269
Was thanked: 16 time(s) in 15 post(s)
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Courtney,
I had asked the above question about the Medicare Jurisdiction B allowed amount for E0486.
A claim for a patient of ours was recently processed with an allowed amount of $1158. I had been told by the insurance that this allowed amount was set at 115% of the Medicare allowable.
Doing the math, this would mean this insurance company showed the Medicare allowable to be about $1007.
This is quite different than the $1300 you had showed. Do you know if the fee has changed/updated at all?
I am just trying to determine if this insurance company underpaid us. I was told we can submit an appeal if we disagree, but that we needed to provide documentation to support this. Since our doctors/office are not contracted with Medicare, I don't have any EOBs to submit as supporting documentation. But I figure I could maybe try anyways without it.
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Rank: Administration
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Hi Guest!
Yes i hear of this situation quite often, as Medicare DME has not published their allowed amounts for E0486 on their fee schedules, so when an insurance company says they based their rate on Medicare, the only people who can argue with them are ones that have seen recent EOB's from Medicare proving otherwise!! :)
It is always possible Medicare will change/update the allowed amounts on these services. However, what I can tell you is that based on several claims for E0486 to Medicare that our billing services has processed for clients in the last 6 months, the allowed amount appears to still be in the $1300 range. Some states in DME jurisdiction B are slightly lower than others - for example we generally see more like $1280 in Illinois & Ohio, but more like $1330-50 in Wisconsin & Michigan.
Hope this helps!
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