11/06/2018

Payer Issue Tracking Page

Last Updated 11/7/18

WPS MEDICARE

10/25/18 - WPS is rejecting claims for ESAs J0881 and J0885 when members are following the diagnosis, modifier and submission requirements within the WPS LCD.  MSHO sent examples to WPS and asked for the system to be corrected.

11/5/18 - WPS Response:

Thank you for your inquiry regarding LCD L34633 Erythropoiesis Stimulating Agents (ESAs) and reporting denials for payment.
I contacted our Systems department regarding the October revision/update.  It was brought to our attention there was conflicting information in the current edit. The edits have been revised to support the appropriate ICD-10 CM Codes for Group 8 Paragraph:  3. Myelodysplastic Syndromes (MDS) for J0881 or J0885.
An adjustment of denied claims in J5 and J8 is being processed over a 2 - 3 week time frame to verify claims within the system have been cleared and included in the mass adjustment.
The mass adjustment will occur automatically and your remittance notice will reflect this information. 
 
MCS Claims Processing Alerts (for Part B) will be published on 11/05/2018: 
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/mcs-system-alerts/
 
It is important to point out that claims can deny for a multitude of reasons.  All services must be reasonable and necessary, documents must be properly signed, and other documentation requirements must be met. If you believe the providers need further information regarding this notification or if they find that their claim(s) meeting this criteria haven’t been appropriately adjusted by 12/01/2018 please feel free to have them contact our Customer Service Center.

NOTE:  MSHO feels this is progress, however, it seems there are still issues with claims for chemotherapy induced anemia and MSHO will continue to address this with WPS.

MEDICAID

Please see the Medicaid section of this newsletter for updates.

BCBSM

No BCBSM system problems reported at this time.

BCN

No BCN system problems reported at this time.

MEDICARE PLUS BLUE (MPB)

No MPB system problems reported at this time.

NOTE: If you have a payer issue that you believe is a system problem and you do not see it listed above, PLEASE report it to MSHO! 

To report, email the description of your issue, including the ICN Number, date of service, provider number and patient contract number to billing@msho.org.  Do not include the patient’s name.

REMINDER – MSHO’s role is to resolve payer issues that will/can impact all members; we do not address individual claim issues. Unique, patient specific issues should not be reported.