Reporting claims correctly and obtaining required prior authorizations reduces claim rejections and member appeals

Over the past several months, we’ve noticed an increased number of member appeals. Verifying member benefits and eligibility, reporting your claims accurately and obtaining required prior authorizations reduces your claim rejections and the number of member appeals.

Most claims are rejected because a claim submission contained incomplete documentation or incorrect coding for a service. Once the missing required information is submitted, the claim may be approved, avoiding an appeal.

Here are four common examples of incomplete or incorrect documentation:

• A laboratory submits a claim using a medical diagnosis code when it should be using a routine diagnosis code. This happens most frequently when lab tests are submitted by a primary care doctor as part of an annual health maintenance exam that is covered under the Affordable Care Act. In these cases, the lab services are considered routine, not medical, and the services should be coded as such.**
• There are laboratory tests (e.g., thyroid tests) that are considered diagnostic and are only covered with a medical diagnosis. These lab services should only be coded as medical, not routine.
• Infusion providers request prior authorization without supporting information. The authorization should be from the prescribing physician.
• A doctor’s office requests prior authorization for a drug but neglects to:
• Submit the correct prior authorization form for the drug.
• Include clinical information and member information.
• Complete the diagnosis field.
• Include chart notes or lab work that confirms the need for the drug, which supports the coverage requirements.
• Sign the prior authorization form.***

As a reminder, be sure to code services correctly and submit the appropriate documentation.

**You can access a list of Blues preventive services codes with no member cost sharing on web-DENIS.

• From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Under Health Reform, click on Information, and then on Blues preventive services codes with no cost sharing.

***For more information about drug prior authorizations, see this month’s installment of “Training Tips and Opportunities” by clicking here.