Posts Tagged ‘Medical Billing’

List of HCPCS Categories

December 11, 2013

The letters at the beginning of HCPCS Level II codes have the following meanings:

  • A-codes (example: A0021): Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental
  • B-codes (example: B4034): Enteral and Parenteral Therapy
  • C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment System
  • D-codes: Dental Procedures
  • E-codes (example: E0100): Durable Medical Equipment
  • G-codes (example: G0008): Temporary Procedures & Professional Services
  • H-codes (example: H0001): Rehabilitative Services
  • J-codes (example: J0120): Drugs Administered Other Than Oral Method, Chemotherapy Drugs
  • K-codes (example: K0001): Temporary Codes for Durable Medical Equipment Regional Carriers
  • L-codes (example: L0112): Orthotic/Prosthetic Procedures
  • M-codes (example: M0064): Medical Services
  • P-codes (example: P2028): Pathology and Laboratory
  • Q-codes (example: Q0035): Temporary Codes
  • R-codes (example: R0070): Diagnostic Radiology Services
  • S-codes (example: S0012): Private Payer Codes
  • T-codes (example: T1000): State Medicaid Agency Codes
  • V-codes (example: V2020): Vision/Hearing Services

Billing Q&A: What are HCPCS?

December 4, 2013

HCPCS stands for Healthcare Common Procedure Coding System (HCPCS). For Medicare and other health insurance programs to ensure health care claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II code set is one of the standard code sets used by medical coders and billers for this purpose. The other, HCPCS Level I, is comprised of CPT (Current Procedural Terminology), copyrighted by the American Medical Association (AMA).

Sometimes described as the “hall closet of coding,” HCPCS Level II serves several needs. The HCPCS Level II code set is made up of five-character alpha-numeric codes representing primarily medical supplies, durable medical goods, non-physician services and services not represented in the Level I code set (CPT®). HCPCS Level II includes services such as ambulance, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office. It is also used as an official code set for outpatient hospital care, chemotherapy drugs, Medicaid and other services. The Blue Cross Blue Shield Association and the American Dental Association (ADA) post their procedure codes as part of HCPCS Level II. The Centers for Medicare & Medicaid Services (CMS) often uses HCPCS Level II to post codes for the tracking of demonstration projects and new technologies.

The development and use of HCPCS Level II began in the 1980s. In 2003, the Secretary of Health and Human Services (HHS) delegated authority under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) legislation to CMS to maintain and distribute HCPCS Level II codes. The code set is updated quarterly based on public input, which includes feedback from providers, manufacturers, vendors, specialty societies, the ADA, Blue Cross and others.

Billing Q&A: Covering for a Colleague

November 6, 2013

In part of our Question & Answer Series, today we address a common question about how to do billing when you are covering for another physician.

Q:  If I am covering for another physician and see some of his/her patients during his/her absence, are these patients considered new or established?

A:  The CPT guidelines specifically address this in the E/M services guidelines section in the front of the CPT manual, under the heading “New and Established Patient”.  “In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.”

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

So what does this mean?  Let’s use an example.  Physician A is on vacation and Physician B is taking Call Coverage while the physician is out of town.  Patient makes an appointment to see On Call Physician (Physician B).  Patient is established with Physician A and would have seen Physician A except he/she is out of town.  Therefore the visit is billed as an Established Patient.

ICD‐9 AND ICD‐10 Diagnosis Code Format and Differences

June 26, 2013

ICD‐9‐CM diagnosis codes vs ICD‐10‐CM diagnosis codes

  • 3‐5 characters in length vs 3‐7 characters in length
  • Approximately 14,000 codes vs Approximately 69,000 available codes
  • First digit may be alpha (E or V) or numeric & Digits 2‐5 are numeric vs Digit one is alpha & Digits two and three are numeric & Digits 4‐7 are alpha or numeric
  • Limited space for adding new codes vs Flexible for adding new codes
  • Lacks detail vs Very specific
  • Lacks laterality vs Has laterality
  • Difficult to analyze data due to nonspecific codes vs Specificity improves coding accuracy and richness of data for analysis
  • Codes are non‐specific and do not adequately define diagnosis needed for medical research vs Detail improves the accuracy of data used for medical research
  • Does not support interoperability because it is not used by other countries vs Supports interoperability and the exchange of health data between other countries and the United States

Why do we need ICD-10?

June 19, 2013

ICD‐9‐CM is outdated, over 30 years old, and cannot adequately accommodate the dramatic advances in
medicine and medical terminology. Many categories are full and not descriptive enough. Originally utilized for indexing purposes in the hospital inpatient setting, it was never intended to be part of the reimbursement process.

An effective coding system needs to be:

  • Flexible enough to quickly incorporate emerging diagnoses
  • Specific enough to precisely identify diagnoses and procedures resulting in
    • a reduction in claims denials due to increased granularity
    • improved coding accuracy
  • Able to support health IT and data exchange initiatives facilitating
    • data exchange between the U.S. and other countries
    • public health surveillance
    • improved quality of care measures and disease management

The ICD-10-CM Foundation and Background

June 12, 2013

Definition of Terms

In order to be able to discuss the transition from ICD‐9‐CM to ICD10‐CM, you first need to understand
the “language” in which the new coding process communicates. Following are terms you need to know.

Important Terms for ICD-10

Covered Entity: Providers, payers and clearinghouses who conduct specific administrative transactions electronically.

EDI: Electronic Data Interchange. Usually used in conjunction with the transmission of health data between providers and clearinghouses/insurance payers.

EHR: Electronic Health Record. This acronym is interchangeable with EMR (Electronic Medical Record). Generally means software that digitally stores patient charts and automates patient care functions such as computerized order entry and ePrescribing.

GEMs: “General Equivalence Mapping” is an approximate conversion and reference
mapping system that attempts to include all valid relationships between the codes in ICD‐9‐CM and ICD‐10‐CM. The relationships can be “one to many,” “many to one,” and in some cases, “one to one.” GEMs is an excellent tool to be used for ICD‐10‐CM staff training and chart auditing.

HIPAA: Health Insurance Portability and Accountability Act of 1996 established not just new rules for ensuring the privacy of health records but also set standards for the electronic transaction of interchanged health data.

HHS: The U.S. Department of Health and Human Services.

ICD‐9‐CM: The Diagnosis Coding lexicon currently in use. It is outdated, inflexible and many categories are full. ICD‐9‐CM contains approximately 13,000 diagnosis codes using a 5 numeric character structure and is electronically communicated using the traditional v.4010 data format.

ICD‐10‐CM: The Diagnosis Coding lexicon mandated for use on Oct. 1, 2014. Developed by World Health Organization (WHO), and used in most industrialized nations, this code structure requires a new data format (v.5010) because it contains up to 7 alphanumeric characters unlike the 5 numeric characters used in ICD‐9‐CM. Comprised of approximately 68,000 codes, it requires providers to code and document to much greater “specificity”.

ICD‐10‐PCS: For use in Inpatient Hospital procedure coding only. Physician outpatient settings will continue to use CPT‐4 to report procedures and services.

O.N.C.: Stands for the Office of the National Coordinator for Health Information
Technology and is a division of the U.S. Department of Health and Human Services (HHS). Under ONC, there are three bodies that can certify Electronic Medical Record technology for “Meaningful Use”.

Placeholder: When a seven character ICD‐10‐CM code requires a seventh character but the sixth position character has no function (e.g. no category, etiology or location), a “placeholder” consisting of the letter “X” is inserted in the sixth character position in order to hold that place in the code so that a seventh character can be used.

PM Software: “Front End” practice management software that schedules, tracks and codes patient encounters. (As opposed to the automated charting functions of EMR).

R.A.C. Audit: Recovery Audit Contractor ‐ The RAC Program’s purpose is to reduce improper Medicare payments and implement actions to prevent future improper payments. The demonstration program in 3 states started in 2005. 3 more states were added and by 2008, $1.03 billion were recovered from improper payments.

Role Based: Used to describe a type of training strategy that focuses the amount and type of training on job classification rather than general training for an entire group. In this context for example, you should consider a different level of training for your physicians (documentation training) than for your coding staff (full ICD‐10‐CM training).

Sequela: An aftereffect of a disease, condition or injury. Also called a “late effect.”

Specificity: In this context, “specificity” is a term used to describe choosing the diagnosis code that is the most descriptive possible given the available provider documentation.

V.5010: An electronic data reporting format scheduled replacing V.4010 on Jan. 1, 2012. Electronic testing of transactions using V.5010 commenced on Jan. 1, 2011. This new data format is required because the new ICD‐10‐CM codes are comprised of up to 7 alpha numeric characters and the old data format currently in use (v.4010) is unable to accommodate ICD‐10‐CM. (On Nov 17, 2011 CMS announced a 90‐Day period of enforcement discretion.)

W.E.D.I.: Comprised of a cross section of the health care industry, the Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of Health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency and to reduce costs of the American healthcare system. Formed in 1991 by the Secretary of Health and Human Services (HHS), WEDI was named in the 1996 HIPAA legislation as an advisor to HHS and continues to fulfill that role today.

WHO: World Health Organization is made up of representatives from numerous
countries that create policy and develop health programs to be adopted on a
world‐wide basis. The WHO developed ICD‐10.

Verify Texas Medicaid Eligibility

February 7, 2013

Each person approved for Medicaid benefits gets a Your Texas Benefits Medicaid card. However, having
a card does not necessarily mean the patient has current Medicaid coverage. You must still verify
eligibility. There are several ways to do this:

• Swipe the patient’s Your Texas Benefits Medicaid card through a standard magnetic card reader,
if your office uses that technology.

• Search for the patient using, a secure website with a variety
of useful features for Medicaid providers.

• Use TexMedConnect on the TMHP website at

• Call the Your Texas Benefits provider helpline at 1-855-827-3747.

• Call Provider Services at the client’s medical or dental plan.

Important: Do not send patients who forgot or lost their cards to an HHSC benefits office for a paper
form. They can get a new card mailed to them by calling 1-855-827-3748. Medicaid members also can go
online to order new cards or print temporary cards. For instructions, visit
and click Learn more about the Your Texas Benefits Medicaid card.

EHR Incentive Payment Audits

January 31, 2013

EHR Incentive Payment Audits

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized the implementation of the Texas Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid/CHIP Division of the Texas Health and Human Services Commission (HHSC) began making incentive payments to eligible providers and eligible hospitals in 2011 for the adoption, implementation, upgrade, and meaningful use of certified electronic health record technology.

The HITECH Act requires states to conduct audits of payments to providers and hospitals participating in the incentive program. HHSC has contracted with the CPA firm of Davila, Buschhorn & Associates, P.C. to conduct audits of incentive payments on behalf of the State.

Representatives of Davila, Buschhorn & Associates, P.C. will be contacting providers who have been selected for audit. If you receive a notice of audit, please respond within ten (10) days with all requested information. The information you provide will be used for the sole purpose of the Texas Medicaid EHR Incentive Program audits.

Steps to Avoid EHR Incentive Payment Delays

January 24, 2013

Eligible professionals who want payments assigned directly to them must have Social Security number on file with TMHP

Eligible professionals (EPs should be aware of the following before beginning enrollment in the Texas Medicaid Electronic Health Record (EHR) Incentive Program:

If you will be assigning the incentive payment to yourself, your Social Security number (SSN) MUST be on file with TMHP and linked to your Texas Provider Identifier (TPI).

To verify that your SSN is on file with TMHP, send an email to with your name and individual National Provider Identifier (NPI).

If your SSN is not on file with TMHP before you begin your enrollment in the program, your incentive payment will be delayed.

EHR Incentive Program Overview

January 17, 2013

Under the provisions of the HITECH Act, State Medicaid programs are establishing EHR Incentive Programs.  These programs provide for incentive payments to certain health care professionals and hospitals that meet specific eligibility requirements when they adopt, implement, and meaningfully use certified EHR technology. To be eligible for incentive programs, health care professionals and hospitals must fall within the defined classifications and meet minimum Medicaid patient volume thresholds. Providers can determine whether they are eligible at this link.

Eligible professionals and hospitals must also meet meaningful use criteria.  Over time, meaningful use criteria will be broadened.  Minimally, a meaningful user of certified EHR technology must meet these three requirements:

  • Demonstrate use of certified EHR technology in a meaningful manner, including e-prescribing
  • Demonstrate connectivity to other providers to improve access to the full view of a patient’s health history
  • Use certified EHR technology to submit, in a form and manner specified by the Secretary of HHS, information on clinical quality measures and other measures

The final rule on specific meaningful use criteria was released on July 13, 2010.  It outlines in greater detail what participating providers will need to do to qualify for the Medicaid EHR incentive payments. The final rule can be reviewed:

CMS Medicaid Payment Rule

January 10, 2013

CMS held a call on the Medicaid PCP payment rule on Wednesday, December 12, 2012.  The following summary of that call.


They will issue more guidance within a month as Q/As at

Physician Self-Certification:

To qualify for payment physician has to self certify, indeed, but responsive to the many questions they received on this issue (and most of the questions they received were on this singular issue), CMS explained they view the requirement as a two step process. First one must self-attest but then (as the second step) one has to support the self-attestation. So they suggest that they are not really defining it as ‘self-certification’ in a conventional sense. Further, no one can attest on behalf of the physician – physicians are required to do that on their own.

E&M Codes Identified in the NPRM:

Final rule now clarifies that states are not required to provide payments for codes in that range that are not otherwise eligible for payment under their state plan. Also clarifies that the 2009 base payment amount for codes added to the E&M range since 2009 and currently reimbursed by the state will be zero. Additionally recognizes that some states allow providers to bill using local codes – higher payment will be available for services billed using these codes if the state as part of the required state plan provides a crosswalk of those codes to the specified E&M codes (so they can continue to use the local codes, but they have to provide a crosswalk that will be approved or rejected by CMS as part of the SPA approval process).

Additional Parameters of Payment:

Final rule defines 2009 base Medicaid state plan rate as excluding performance based supplemental payments such as bonus, Pay for Performance, and incentive payments since they are not part of the fee schedule payments. However, it makes clear that volume based payments such as those made to physicians associated with certain academic medical centers must be acknowledged as part of the base rate. As required by statue, the final rule continues to provide for 100% FMAP on the differential between the 2009 Medicaid state plan rate and the applicable 2013 and 2014 Medicare rates. States that have lowered their rates since 2009 will receive federal match at the regular FMAP for the difference between the 2009 rate and the existing lower state plan rate. There are no waivers or exceptions possible.

Identification of the 2013/ 2014 Medicare Fee Schedule Amount:

CMS just published the final rule establishing the Medicare rates for CY 2013. Under current law, the Medicare conversion factor is expected to be $25 unless Congress intervenes to adjust the conversion factor upward. The conversion factor currently is $34. In 2009, the conversion factor was $36, therefore it appears that states will be expected to pay rates in 2013 for codes identified in the final rule that are developed using the 2009 conversion factor and 2013 RVUs.

The final rule no longer requires that states make all Medicare service and locality adjustments although they can do so if they wish. States can choose to pay all services as the Medicare office rate (non facility rate) as opposed to paying at facility rate when service is provided in a hospital setting. Can also choose to pay each E&M code at a rate that represents the Medicare mean over all counties rather than pay the Medicare rate applicable to specific geographic location. Continues to permit state flexibility in determining whether to and how often to update rates to conform to changes in Medicare physician fee schedule. Rule also clarifies that higher payment may be made as adjustments to rates or if in a lump sum basis – no less frequently than quarterly and these additional reconciling amounts methodologies will be specified to the state plan. Rule continues to require payment for codes not reimbursed by Medicare using a CMS developed fee schedule that will be based on the recommended RVUs and the CMS published conversion factor.


Final rule continues to require that states submit SPAs to implement the payment increase but now indicates that CMS will provide a template. The rule now indicates that SPAs will be required to specify (1) whether the state will make a site-of-service adjustment or reimburse all codes at the Medicare rate applicable to the office setting, (2) whether the state will make all Medicare locality adjustments or use a statewide rate per code that reflects the mean value over all counties of the Medicare rates (3) the manner in which states will make higher payment (whether as a fee schedule or aggregate supplemental payment ) and (4) the codes which will be paid by the state at the higher rate and the codes that have been added to the fee schedule since 2009. If the state does not use HIP AA compliant codes, the SPA must provide a crosswalk to the covered E&M codes.

The final rule confirms that the State plan requirement applies – meaning the SPA may be effective of the first day of the calendar quarter in which it is submitted, so states will have until March 31, 2013 to submit their SPAs Then CMS will have 90 days to review the SPAs and approve, deny or request additional information. 100% FFP will not be available for eligible primary care vaccine administration until the SPA is approved. CMS will work with states to expedite approval of the SPA. CMS will also provide a template to facilitate this requirement. No payment will be dispersed until the SPA is approved but, again, CMS believes the template will greatly expedite the development of the SPAs. MDES (the system that states report Medicaid expenditures) has been modified so that it has separate lines to report services eligible for the 100% match. There is also separate reporting for FFS payment and managed care payment.

Program Evaluation:

Rule requires that states submit to CMS at such time/in such form that CMS specifies information relating to participation by eligible physicians and use of E&M codes described in regulation as of 7/1/09 and for CY 2013. This data will help evaluate the impact of the rule on access to services.

Managed Care (Camille Dobson, Senior Policy Advisor for MMC):

For states that use a managed care delivery system, CMS revised section 438804 from the NPRM to require states to submit and receive approval from CMS for two methodologies (1) for identifying the 2009 base line rate for primary care services that were in capitation payments at that time and the differential in capitation rates between that amount and what they are paying in 2013 or 2014 that is eligible for 100% FFP. CMS made this revision because they determined, after receiving comments, that it was important to have a separate explanation of the 2009 base year rate for primary services since there are states that had populations or services that were not in managed care in 2009. In order to better evaluate the amount of difference in the payments that were eligible for 100% of FFP, they are now working with states on how to do this – as well as with Deloitte, which whom they have contracted for technical assistance.

The second change from NPRM is that the timeline is extended for submitting those methodologies and receiving CMS approval – thru end of first quarter of 2013 (original deadline was 1/1/13). This also synchs-up with the timeframe for submission of the SPA. CMS staff in regional offices will review and approve both of those methodologies to ensure states are using the most accurate and reasonable data available to accurately identify the amount eligible for the 100% federal match. Once those methods are approved, CMS will follow rapidly (hopefully) with approval of managed care contract amendments and rate setting documentation that reflect those managed care methodologies. Once states receive approval of contracts AND rates, payments will be made retroactively to 1/1/13 to the health plans. CMS gave flexibility to the states on how to disseminate payments to primary care providers, recognizing the number of different delivery systems that exit in managed care plans but they are clear that the benefit of the increased payment must go to the provider. Much like FFS: documentation must be provided by the plans to the state that the requirements of the rule are carried out. CMS is not specifying how that documentation or reporting must occur but states are required to specify that in their health plan contracts to substantiate that the primary care rate was delivered to eligible providers. Plans must also make available to the state for verification of payments for any audits or reconciliation processes and also for the evaluation component.


Section 1202 of ACA specifically identifies vaccines as being included in the payment increase – they are an integral part of the practice of primary care providers. More importantly, the inclusion aligns payment structure for vaccines and will hopefully result in increased provider participation and access to pediatric vaccines for children in Medicaid. Payments will be made at the lesser of the VFC regional vaccine for children or the Medicare physician fee schedule rate. Because the coding change for vaccines took place in 2009, states will have compute the vaccine administration code value – the formula to do this was included in the final rule. However, if states can show to state plan what was paid for vaccine administration codes on 7/1/09 – states can use that rate and will not have to develop another. The SPA template includes a section on vaccine administration and each state mush complete this template before it can receive increased payments. Coding change also added a code for additional components in a combination vaccine. The VFC program only allows a single payment for each shot administered and so the VFC doesn’t pay for this additional code. Here, the VFC rules also apply to the final rule.

The final rule also included an updated fee schedule for the VFC program. It has not been updated since 1994. There were no other changes to VFC program, so states continue to have the flexibility to determine their state’s regional maximum fee.


Any additional questions should be directed to

How To Write an Effective Appeal Letter

April 30, 2012

The following is a list of steps to preparing an appeal:

  1. Address the appeal letter to the Insurance Company who paid/rejected the claim.
  2. If this is your 2nd Level Appeal or 3rd Level Appeal, notate that on the header also.  If it is your first there is no need to be specific.
  3. Put the Date that you are preparing the appeal on the appeal letter.
  4. Address the appeal to:  To Whom It May Concern.
  5. Include the Patient Name, DOB, ID#, DOS and Billed Amount of the claim originally submitted.
  6. Point out the reason for claim denial.  Example: This claim was denied for timely filing however according to our records this is incorrect.
  7. Provide an explanation as to why this is incorrect based off of:  Contract, Fee Schedule, Timely Filling Submission Dates, Coding Guidelines, State Rules & Regulations (resources for Texas: TID, TMB, TMA, TCMS), Federal Rules & Regulations (CMS, AMA, HIPAA, OIG, HHS, FDCPA, PHI, Prompt Pay Act), Payor Guidelines, Provider Information or Credentials that rendered the services, Medical Necessity, Patient Benefits, Authorization on file, Any other applicable reason for an invalid denial
  8. Close with expectations:  Please reprocess for payment according to our contract, Please reprocess according to our fee schedule, Please see attached proof of submission for timely filing, Please reprocess per coding guidelines (list the exact coding guideline), Please reprocess according to rules & regulations (list the exact rule or regulation that they violated), Please correct the CPT Code/ICD9 Code, Please reprocess with attached information regarding medical necessity, Please make additional payment within 14 business days
  9. Attach any applicable documents:  Contract (if necessary), Fee Schedule (if necessary), Proof of Timely Filing, Documentation on Coding Guidelines, Documentation on any State and/or Federal Rules & Regulations, CPT, HCPCS or ICD9 Code information, Copy of Provider information (Provider License, Provider Credentials, Practice Information, etc), Medical Records, Copy of Patient Benefits, Copy of Authorization, Or any other further documentation to support the denial

Utilize these 9 steps and you will have the foundation for an effective Appeal Letter to win the fight against the insurance carrier!  We wish you great success!  If we can assist you further, please to not hesitate to contact us at 817.239.6595

[The steps are written for Providers in the State of Texas…some of the resources listed may not apply to your state.]

Poll: Did you take a Medical Billing Course?

April 27, 2012

We would like your participation in a Poll that we are doing.  If you wish to participate, please email me.

Did you take a Medical Billing Course to learn your field of study?  If so, was it a Certified Medical Billing Course?  Will you share with us who you took your course through?  What did you spend to take the course?  If you would take the course again given what you know now?  Are you in the field you went to school for?  How long have you been in Medical Billing and/or Medical Coding?

We would appreciate your participation in this questionnaire!  If you would like to email us your story, we will publish it on our blog.

Lessons learned from Beta Client experience

April 23, 2012

If you follow my blog, you would have read a post here about my latest Beta Client experience.  This is not my first time to ever do this and I have never had a previous bad experience in being a Beta Client; however there is always a first for everything.

Anytime something doesn’t go as planned, I always try to evaluate it.  With that, here are 5 Lessons I learned from the latest Beta Client experience:

  1. Don’t take people at their word.  People change.  When the going gets tough, many times people quit and don’t fulfill their commitments and follow through on their promises.  This means even great Entrepreneurs that state they will do whatever it takes to make something happen.
  2. Define expectations in writing of what a Beta Client means and who will be doing what.  Even though someone says they will work with you jointly on a project, if they don’t do what they said they will do, you need something to fall back on.  No assumptions on what that means.
  3. Don’t expect the other party to put in as much “free” services as you do.  You will always have to give 150% more than the other party does.  Don’t go into a deal unless you are willing to be the one doing 150% of the work (or more).
  4. Be sure to have a backup plan in case the current plan doesn’t work out as anticipated.  You have heard the saying “Don’t have your eggs all in one basket”.  Another wards, don’t be so into this deal that you don’t have another option if it falls through.
  5. When the deal is off, realize its a done deal and move forward.  Don’t cry over spilt milk.  It is already spilt and no way to get it back into the cup.


A Beta Client Experience

April 20, 2012

Working with Physician’s offices that are start-ups, means they do not have the same capital to build their Medical Practice with.  This places challenges on many fronts when trying to find ways to be compliant with the Federal Regulations and making the Practice efficient and profitable.

In seeking to assist a client with the implementation of a Practice Management System with an Electronic Medical Records System (EMR), we (the software consultant for my client, my client and I) opted to be a Beta Client for a Texas-based company.  Their system was built for Chiropractor’s and they wanted to be able to advance and take their product to the next level.  The system was web-based, very user-friendly and had met the Meaningful Use requirements and was certified.  The company agreed to provide support and enhancements to meet the criteria needed by our specialty in exchange for us building the database, providing the feedback and testing the product for free along with a very low monthly maintenance fee.

After 5 months of working in the database, building the templates, creating the profiles, loading the CPT Codes, creating the Fee Schedules, loading the ICD9 Codes, inputting our patient base, etc the vendor has reneged on their agreement with us.  Their decision really made this a tough week to learn that they are not willing to fulfill their part of the deal with us.  The hard-core facts of the amount of time I have spent on something I won’t get a return on and the money spent to pay employees to load information in a system that we won’t be using, is gone.  We are back to square one, 4 months into a new year, with no more headway now then we were in the Fall of 2011 towards meeting Meaningful Use. This is a huge setback and a difficult situation that I currently am not aware how I am going to address, other than a meeting this next week with the Software Consultant and my client to discuss our options.

ICD-10 is delayed another year…

April 11, 2012

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced Monday, April 9th, a proposed rule that would establish a unique health plan identifier under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed changes would save health care providers and health plans up to $4.6 billion over the next ten years, according to estimates released by the HHS today. The estimates were included in a proposed rule that cuts red tape and simplifies administrative processes for doctors, hospitals and health insurance plans.

“The new health care law is cutting red tape, making our health care system more efficient and saving money,” Secretary Sebelius said. “These important simplifications will mean doctors can spend less time filling out forms and more time seeing patients.”

Currently, when health plans and entities like third-party administrators bill providers, they are identified using a wide range of different identifiers that do not have a standard length or format. As a result, health care providers run into a number of time-consuming problems, such as routing errors of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The rule simplifies the administrative process for providers by proposing that health plans have a unique identifier of a standard length and format to facilitate routine use in computer systems.  This will allow provider offices to automate and simplify their processes, particularly when processing bills and other transactions.

The proposed rule also delays required compliance by one year– from Oct. 1, 2013, to Oct. 1, 2014– for new codes used to classify diseases and health problems. These codes, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include new procedures and diagnoses and improve the quality of information available for quality improvement and payment purposes.

Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

The proposed rule announced today is the third in a series of administrative simplification rules in the new health care law. HHS released the first in July of 2011 and the second in January of 2012, and plans to announce more in the coming months.

More information on the proposed rule is available on fact sheets at

The proposed rule may be viewed at Comments are due 30 days after publication in the Federal Register.

Credentialing with Insurance Companies

April 9, 2012

We will be doing more Blog Posts on the subject of Credentialing, but today’s is simply an overview for you to understand what it is.

Credentialing, as defined by Texas Administrative Code (TAC) §10.82, is the “process for selection and retention of network doctors and health care practitioners” (providers). Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy.  The credentialing process is part of the required Quality Improvement Program described in 28 TAC §10.81 and Texas Insurance Code, §§1305.301-1305.304. All certified workers’ compensation networks are required to document, create policies and procedures, and develop written criteria for credentialing network providers.

The initial credentialing process may begin with a provider submitting a completed Texas Standardized Credentialing Application to the Insurance Company and Network in which they wish to participate. The Credentialing Department and/or Committee will verify items such as the applicant’s work history, current professional liability insurance, education, board certification (if applicable), history of loss, sanctions or other disciplinary activity. The process may also consist of an on-site visit to assess the applicant’s location of practice or facility.  The applicant must be notified of the credentialing committee’s decision no later than 60 days after the decision. The WCNet is required to re-credential each participating credentialed provider every 3 years.

Many health care facilities, institutions and providers conduct their own credentialing, through this is a service that can be paid for and done by a credentialing specialist or electronic service, with review by a medical staff or credentialing committee.  It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership.

As Texas is not an “any willing provider” state, the WCNet is not required to contract with a provider applicant. However, pursuant to 28 TAC §10.82, a provider has the right to review the information submitted to support the credentialing application, correct erroneous information and the right to be informed of the status of their credentialing or re-credentialing application.

The process is generally an objective evaluation of a subject’s current licencee, training or experience, competence, and ability to provide particular services or perform particular procedures.

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment).  Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.


Do you do your own credentialing or do you hire someone else to do it?

7 things to consider in taking a Medical Billing Course

April 4, 2012

I get asked all the time how to get into Medical Billing.  What is the best course to take?  How to be able to do it and work from home?  All of us really would love to have a job that paid well that we didn’t have to work very hard at. I don’t know of many of those types of jobs out there.  Good money for little effort?  Convenience of working from home with a guaranteed income?

You can read my story of how I got into Medical Billing here along with some information on the Medical Billing Industry here.  I want to give you some things to consider if you are looking to do a Medical Billing Course:

  1. Evaluate the course.  What do they teach you?  If they only are teaching you Medical Coding (ICD9 & CPT Codes) this is not going to give you all the skills you need to do the job, though it will be a start.  Medical Billing and Medical Coding are not the same thing.  You can learn more about the difference here.
  2. Evaluate the teachers.  How many years experience do they have in Medical Billing and/or Medical Coding?  What types of specialties have they worked in?
  3. Evaluate their promise to get you a job.  Many of these courses promise to get you a job in the Medical Field.  In my experience, this happens very rarely.  Physician’s offices don’t just hire people because they have schooling.  You have to be willing to start at the ground up and work up, just like anyone else.  Schooling does not replace on the job experience nor actual hands on experience.  Schooling is just knowledge.
  4. Evaluate the cost.  How much will you spend for this course in time, energy and money verses if you took a job at a local Medical Practice and worked your way up to this position?  Many times spending time, energy and money on something helps you, but that is not always 100% the case.
  5. Evaluate why you want to take the Medical Billing Course.  Is it because you want to learn something new?  Is it because the industry and career field intrigue you?  Or are you simply wanting money and an easy way you think you can get it?  Many of these programs guarantee you will be making lucrative money working from home.  In all seriousness, you can make money, but it is not going to be this huge income that will allow you to be “rich”.  It takes a lot of hard work, determination, understanding of all the industry rules & regulations (both on a State and Federal level), attention to detail, accuracy and prompt response.  Secondly, working from home doing Medical Billing is not the common everyday scenario.  Is it possible?  Yes, but in all liklihood you will not start out that way.
  6. Many of the advertised Medical Billing Courses out there are scams.  Research them.  The software they train you on is one of many that are out there; literally there are hundreds of different programs.  You need to learn the skills of the job, not how to operate a system.  Check with the Better Business Bureau to see if there have been complaints.  Ask to speak with other students who have taken their course, would they recommend you to take the course?  Would they spend the money for the course all over again?  Did they achieve their goal by taking the course?  Are they in a job that is what they went to school for?  What sort of pay range are they at?  If they can’t give you the answers you are looking for, then it is probably not going to work for you either.
  7. If you do take a Medical Billing Course, you may need to volunteer at a Non-Profit Medical Center to get your foot in the door.  You may have to take a position as a Medical Receptionist first to be able to help the Medical Billing Team.

Attend all the Seminars and Coding Classes that are offered in your area to make connections and even find someone who will mentor you.  Remember that you will have to continue to learn, do research, train and educate yourself on your own, for free, to continue to stay up in the Industry and be an employee a company out there wants to hire.  You must understand that Physician’s need confidence that you are going to be handling their money appropriately and accurately, whether you are in-house or out-sourced.  If you want to be successful at Medical Billing, you can, but YOU must put the effort into it.

Texas Clean Claim Requirements

April 2, 2012

Each states has its own guidelines and regulations set forth in various forms of the Healthcare Industry.  The Texas Department of Insurance has guidelines on specific requirements that are needed on a HCFA1500 in order for it to be considered as a Clean Claim.  You can review those documents here on the Texas Secretary of State website.

Do you wonder if the Texas Clean Claim Requirements apply to you?  You can read and find that information here.

A clean claim must be submitted in order for the Prompt Pay Guidelines to apply.  We will review those with you soon!

5010 Tip #3

March 7, 2012

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment.  That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012.  I know.  Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain.  However, I hope by now you are making great strides in the conversion.  If not, I am sorry.  I wish I could fix it with a magic wand, however, I can’t.  I can provide you a few pieces of information that might help you get some cash flow turnaround quickly and will be posting a few tips on Version 5010 that will provide you some resources to help you make headway through to get some answers to your problems.

Are you aware of what has changed with 5010?  Have you researched the areas that are affected with your specialty? Do you realize that if this data is not loaded correctly, your claims will not make it to your clearinghouse?  Understanding the fields and how data is reported on a HCFA1500/CMS1500 Claim Form is a critical step to making sure your data is loaded correctly.  The National Uniform Claim Committee has a document called the 1500 Claim Form Map to the Healthcare Professional 837 File.  Click the link to download the latest version.  It will help you trouble shoot your rejections when you need to know what loop and segment go where in your database!

Come back next week for another 5010 Tip!

5010 Tip #2

February 29, 2012

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment.  That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012.  I know.  Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain.  I am sorry.  I wish I could fix it with a magic wand, however, I can’t.  I can provide you a few pieces of information that might  help you get some cash flow turnaround quickly.  The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your clearinghouse?

Do they have a newsletter?

Do they have a blog?

Do they have a discussion board?

Do they send you weekly tips and suggestions to improve your claims?

Do they have webinars for you to attend (either free of charge or at a cost)?

Have you utilized everything they offer?

The only way to know is to research it and find out.  If you don’t know…google them and see where it goes.  You are liable to learn a lot in a short time frame and maybe even get a nugget that will help you with a current problem you are experiencing.

Come back next week for another 5010 Tip!

5010 Tip #1

February 22, 2012

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment.  That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012.  I know.  Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain.  I am sorry.  I wish I could fix it with a magic wand, however, I can’t.  I can provide you a few pieces of information that might  help you get some cash flow turnaround quickly.  The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your biggest Insurance Carrier?  Is it a commercial insurance carrier or government program?

Do you know if they have the ability for you to file claims directly on their online portal?  If so…have you considered this option?  Did you know about 50% of them do?

Are you aware that claims are processed in 24-72 hours once submitted on this site and that you have a check within 7-10 days?

If the insurance carrier does not have an online portal to be able to submit claims to them, do you know if the insurance carrier has any free software you can use to submit claims?  Medicare does.  It is called PC ACE PRO 32.  You have to have an EDI Agreement in place directly with them and get a unique submitter ID#; however, once you get that, claims are paid within 14days like clockwork.  It is NOT a Practice Management system, it is simply a tool to submit claims…but if you are not getting paid through your clearinghouse it is a viable option to consider in the interim.

If I were to have given CMS any feedback on preparation for 5010, they should have made this an available option and a requirement that all insurance carriers have an option to be able to upload raw data directly to them and/or their clearinghouse along with a portal for online claim submission.

Come back next week for another 5010 Tip!

5010 Nightmare

February 20, 2012

I have been in the Medical Industry for 16 years and I have seen changes over time affect our industry and create problems of such a major impact that you have issues that are referred to as a Nightmare.  Nightmares both literally and figuratively.  Horrific nightmares that all of us dread and seriously hope we never have to face.

This blog has been a way I have communicated tips, resources, and quotes of motivation to inspire all of us in our quest to provide excellent service to our clients, providers and employers.  I read a blog post yesterday by a physician that shared many things they are experiencing with the horrific changes to 5010 on a personal level and how if they can’t get resolution soon, they will have to close their doors.  I read such an article via my AMA email subscription two weeks ago, but hadn’t had a personal story to attach it to.  Having now read that, it made me realize that I have never utilized my business blog for such purposes…however, in light of the serious fiasco of 5010, it prompted me to change and share a few things I have learned along the way to try to encourage my colleagues and providers that are beat down, scarred stiff, discouraged and ready to quit (either because they have to financially or because they are done with this mess).

With the approaching deadline of 5010 Implementation set forth originally by CMS as January 1st, 2012, I told each of my clients that this change will either be a hoopla (a big deal over nothing) or it will be a fiasco (a horrific mess).  For most of my clients, it has been the latter.  A fiasco that has caused Cash Flow Crisis Issues beyond words.

For all of my clients, very little of this could have been avoided.  Why you ask?  Well, all but one of them utilize a software vendor to transmit their claims to the clearinghouse.  Only one of them submits directly to the carrier.  When you utilize a software vendor, you are at their mercy as to what testing they have done, what compliance steps they have taken, what progress they made during “testing phase”, how proactive they are at resolving issues, what information they communicate or do not communicate to the providers, what changes they make without letting you know, along with how effective they are at trouble shooting, let alone their personal experience and knowledge of your specific specialty and/or industry, along with carrier requirements.  Many times, these representatives have the “basic” foundation and understanding of the claims files and data required.  Most of the time the Support Team and/or Customer Service Representatives do not have specific experience to your industry or know your states requirements on a payer level.  If you have worked with a Support Team and Customer Service Representative that does, I applaud you.  No, I don’t applaud you, I am jealous of you because by not working with Support Team and Customer Service Representatives that have that experience and understanding, that only adds the the stress.  For the most part since I have been working on this 5010 stuff beginning in October 2011, I have not.  Utilizing a software vendor and a clearinghouse means that you pay them to be uptodate and compliant on all levels.  That means when they state they provide a service to all industries, they do just that.  When their website says they have completed testing, are compliant, ready for the implementation of the conversion and will work with you to prevent any issues, they should be.  This means they have to fix your issues.  This means that you do not have to figure out what data is wrong.  Or does it?

Let me just tell you that I never dreamed that I would be:

  • analyzing the raw data to find the missing errors because you get told by the EDI Team that they don’t find an issue or they don’t know what is causing the issue, but yet you clearly are getting rejections
  • they pawn you off asking if you read the latest broadcast message that this is a “known issue”, yet they have no resolution or fix yet for this “known issue”
  • educating these Support Team and/or Customer Service representatives on what is wrong and required per ANSI5010 vs ANSI4010 requirements and in many cases providing hard core information to substantiate it because they argue that they have no record of this or that being a requirement
  • providing proof to a Carrier that they rejected my claims by providing them the exact reports they sent back to our clearinghouse, when they state they never got our original claims but we clearly have “Carrier Reports” which are responses directly from the Carrier
  • providing the supposed experts and guru’s on the technical team the 296 page CMS document file on what is required on a HCFA1500/CMS1500 Claim Form to submit a paper claim because they told me that was not a Medicare requirement to be printing on the form even though I showed them the denial from Medicare
  • get into arguments with the EDI team when they state they never knew this stuff and it must be “new” (yes some of it is new, some of it is old requirements being transmitted in a new format but the requirement is not new)
  • when provided an answer that I know will not fix it having to lay out the ground work, be patient and realize that you will have to educate them as a teacher does a student as to why that “fix” will not fix it
  • etc

So what steps would I encourage you to take during this 5010 fiasco?

  1. Know if your carrier is in 5010 production mode or still in test mode.
  2. Confirm if you clearinghouse is converting your files from 4010 to 5010 for you or if you have to make the change in your database for the data to be exported correctly.
  3. Locate your carriers requirements for transmitting a claim electronically and also obtain their requirements for paper claims.  CMS has their information posted out on the internet, it is not a secret.  Each carrier will provide you their requirements if you just make the phone call to them.  All it takes is for you to call them, tell them you want to make sure you are in compliance and ask for their’s is not published on the internet or through the provider portal.
  4. Take the information you get on your carriers requirements and provide that information back to your software vendor and/or clearinghouse and assist them at making the changes.  Believe me, if you do this, you will get resolution much quicker.
  5. If you have the option to file claims directly on the carrier’s website, even if this is double entry because you have loaded the claim in your database and must re-enter the information in their online portal, do so, you will be paid very quickly, on average 7-14days out.
  6. When you know you have the correct information and the EDI team or Support Team don’t provide resolution, hold your ground.  Ask to speak to a manager.  Tell them the case needs to be escalated to a Tier 2 Representative.  Tell them you are sorry, but that won’t fix the problem.  Do another test to show them it doesn’t.  Don’t be afraid to clearly provide answers that “the fix” is not a fix.
  7. Stay on top of the issues.  Give them 24-48hours to respond, if they don’t call and email them.  They will learn after repeated phone calls from you that you mean business, won’t be put off and want resolution.  Remember:  The squeaky wheel is the one that gets the grease.
  8. If you don’t get a response to your claims that you have submitted, drop that bad boy to paper and mail it to the carrier.
  9. Don’t give up!!!  As Dave Ramsey says “In the story of the Tortoise and the Hare, every time I read the book, the Hare always wins the race.”  Meaning:  Slow.  Steady, Consistent, Focused, Determination  = Success
  10. Be patient.  Keep the big picture in mind.  Work this in bite size chunks.  We will win on this conversion to 5010!  I am confident we will!!!


What issues are you experiencing with 5010?

What steps have you done to get success?

Share tips below for other colleagues.  If you wish to write a guest post on my blog, contact me.

Top 5010 Issues

February 8, 2012

Many physician practices have reported numerous problems across various areas of the United States stemming from the transition to Version 5010. The most frequently reported problems have involved:

  • Issues with practice management and/or billing systems that showed no problems during the testing phase with their MAC, but once the practice moved into production phase, found their claims being rejected
  • Issues with secondary payers
  • Rejections due to various address issues (pay-to address being stripped/lost from claims; pay to address can no longer be the same as billing address; no PO Box address)
  • Crosswalk NPI numbers not being recognized
  • “Lost” claims with Medicare Administrative Contractors (MACs)
  • Old submitter validation information not being transferred
  • Certain “not otherwise specified” claims being denied due to not having a description on the claim (CMS sent a notice of correction of this issue January 27, 2012)
  • Sporadic payment of re-submitted claims (with no explanation for rejections)
  • Protracted call hold times (most typically 1-2 hours) when attempting to contact Medicare Administrative Contractors (MACs) for further explanation of unpaid and rejected claims (a problem that dates as far back as November 2011)
  • Unsuccessful claims processing (with no reason cited for rejection) despite using a “submitter” that was approved after successful testing with CMS

Many providers report not having been paid by Medicare and TRICARE since as far back as November 2011 as a result of Version 5010 issues.  They also are not getting all the Carrier Reports back to confirm accepted and rejected status of the transmission of their claims.  Many are experiencing rejections that the Clearinghouse can not explain.  These issues must be monitored and steps taken to ensure that claims are getting processed through to the carriers as quickly as possible.

What have you experienced with the transition of 4010 to 5010 format?  We would love to hear your feedback.

Denials and Issues with 5010

February 6, 2012

As a Medical Practice, you are aware of the impact that our industry is facing as of 01.01.2012…conversion of Electronic Files from the 4010 to the 5010 formats.  The American Medical Association is aware that this is creating many denials and issues with 5010 and therefore has put out documentation on what you can do if you are experiencing claims processing issues.  Please read below:

Since the deadline on January 1, 2012 to convert to the Health Insurance Portability and Accountability Act (HIPAA) Version 5010 transactions, some physicians have been experiencing issues with their claims processing, resulting in lack of payments.

The AMA is aware of issues with claims processing related to the 5010 transition and is addressing these issues directly with the Centers for Medicare and Medicaid Services (CMS). Please inform the AMA and CMS of your issues:

  • Report the problems you are having to the AMA with this form at
  • Visit to access additional complaint forms, including the Centers for Medicare and Medicaid Services complaint form.
  • Submit your problem to for issues you are having with Medicare.

Until these issues are resolved, the following are action items that physician practices can take if they are having issues with their claims and interruptions in their cash flow:

  • If using a billing service or clearinghouse, contact the billing service or clearinghouse to understand where the problem is occurring. Is it related to the data you are submitting? Is it due to the payers’ processing of the claims?
  • If you identify a problem with your practice management system, contact your vendor to have the problem resolved.
  • If you submit your claims directly to the payer, contact the payer to understand where the problem is occurring. Is it related to the data you are submitting? Is it related to problems within their adjudication system?
  • Contact a financial institution about establishing a line of credit.
  • Consider submitting paper claim forms to those payers that will accept them.

What are you doing to stay on top of the changes with 5010?  Are you seeing any impact on your practice?  If you have any tips for other Medical Practices, we would love you to share your ideas below.  We are a community out to help each other be successful!

5010 Review

January 31, 2012

The healthcare industry has been using HIPAA 5010 standards to transmit electronic medical claims for a few weeks. How’s that working for your practice?  Are you seeing denials?  Do you know what to be looking for and get the data fixed?  While it’s tempting to assume that no news is good news, a lack of response doesn’t mean there is not an issue.  Make sure you watch out for any medical claim rejections and denials and fix them as quickly as possible. Some of the problems that could be causing rejections or denials includes:

  • National Provider Identifiers (NPI) need to be used, not an employer’s tax ID or Social Security number.
  • HIPAA 5010 requires that a street address – not PO Box, be used on all medical claims.
  • Providers can use a PO Box for a billing address that receives reimbursement checks. But make sure the payers have that on file and are using it.
  • Speaking of addresses, providers need a nine-digit zip code with the billing and physical addresses.
  • HIPAA 5010 allows as many as 12 diagnosis codes on each claim, but each specific service can only have four codes.
  • Any claim using an unlisted Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code also needs a code description.
  • Healthcare providers must submit a Medicare Secondary Payer (MSP) indicator on the primary and secondary claim when Medicare is the secondary payer.
  • Drug quantity and unit of measurement are required when a National Drug Code (NDC) is listed.
  • All ingredients in a compound prescription must be listed with a HCPCS code.

In addition to watching the number of denials or rejections, make sure the reimbursements match what you expect. Just because the claims get out the door, doesn’t mean they it will be processed correctly for reimbursement.  There are many aspects to the claim process and all must be evaluated.

We hope you are having  success with the transition from 4010 to 5010!

Medical Necessity means just what?

January 16, 2012

When an Insurance Carrier processes a claim and denies for this does not meet Medical Necessity, what do they mean by that?

The term “Medically Necessary” or “Medical Necessity” is defined as a health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are in accordance with generally accepted standards of medical practiced; clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Ultimately the medical record from the Physician or Healthcare Providers documented notes along with an appeal letter to specifically outline the reasons for Medical Necessity in regards to the patient’s case, are the only way to substantiate a case against a denial by an Insurance Company.  If the claim is still denied by the Insurance Company, you can attempt a 2nd or 3rd Level Appeal with the Medical Review Board.