03/04/2019

Payer Issue Tracking Page

Last Updated 3/4/19

WPS MEDICARE

Problem: MSHO has received recent reports of denials for ESAs (J0881 and J0885) for MDS. It appears that the update by WPS changed the diagnosis reporting from needing 2 diagnosis to needing just one primary diagnosis.. MSHO members reported that when they bill their claim with just one of the diagnosis listed on the LCD, they are reimbursed.  MSHO is still investigating.

Below is a list of the acceptable ICD-10 codes from the WPS LCD - REPORT ONLY ONE DIAGNOSIS

Reported 2/4/19 (Thank you Lynne Wilcox for bringing this issue to our attention!)

Update 2/19/19 - MSHO has received reports of additional issues related to wrongful denials of ESAs for Chemo Induced Anemia, MDS and Chronic Kidney Disease.  Examples have been sent to WPS for review and request for system correction.

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No additional WPS system problems reported at this time, with exception of a few outstanding High Dollar Reviews "stuck in the system" and being pulled for immediate review.  If you experience a delay in your High Dollar Review, be sure to alert MSHO via email at billing@msho.org

BCBSM

Problem:  BCBSM has the maximum units for the Rituxan now J-code, J9312, 10 mg, loaded incorrectly in their system.  The Max unit used to be 1,200 mg... and BCBSM has a limit of 20 for the new code (200mg).  This has been reported and BCBSM is looking into it!

Reported: 2/31/19 - (Thank you Lori Peddicord & Sara Gouins for brining this issue to our attention!)

Update 2/19/19- (From BCBSM)  There is currently an update in process.  The HCPCS billable changed with the new code that was released in January 2019, and the quantity limit is being adjusted to meet most members dose needs. The max will be the qty of 200.  I was advised that this change will be retroactive to January 1, 2019.  I do not have any information on an implementation completion date at this time.

Update 3/4/19 - (From BCBSM)  We have been informed that the system has been updated with the correct MUE, however we do not have any confirmed payments.  MSHO is awaiting member offices' confirmation of the fix.

BCN

No BCN system problems reported at this time.

MEDICAID

Please see the Medicaid section of this newsletter for updates.

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.