Forum - Questions & Answers

Jul 21st, 2014 - Melmore 2 

Vision Claims - Improper Denials

Hello,
I have been billing insurance claims for over two years. Just recently, I am suddenly having problems with insurance companies (Aetna and Medicaid) denying the vision insurance claim because I did not send it to the "primary" first. The primary that they speak of is a medical plan only. This has never happened to me before. Is this some new insurance rule?! Or are these companies truly denying improperly? To me it seems it is an incorrect denial. I have had some time (but not enough) to call Aetna on some of these and the rep will recognize that it should not have been denied since there is no other vision insurance for that particular member. Medicaid however, seems to be sticking to their guns and requiring us to bill through the medical plan first. Just seems like a way for them to hold the money longer...they know it will deny through the medical plan.

Thanks for any kind of light you can shed upon this for me.

Jul 22nd, 2014 - shanbull 51 

re: Vision Claims - Improper Denials

Hmm, a few possibilities here. When you mention the Aetna plans, I'm assuming you are referring mostly to commercial plans (not tied to Medicaid in any way)? And these denials are happening to everyone in the same situation (e.g. there is a primary plan, but it has no vision benefits)? If this is the case, it seems that both Aetna and your state Medicaid have both recently activated a new claims processing edit causing the denials. Whether the denials are correct or not is a mystery to me and unfortunately I have no experience in billing vision claims. I would start by investigating your state's Medicaid policies. You should be able to get in contact with someone who can point out where this new policy is spelled out in the Medicaid manual (it will be in the manual if the denials are indeed correct). If this isn't a policy in the manual, this person may be able to help you find out why the denials are being triggered for the Medicaid claims, or at least direct you to someone in their claims processing department who can help. Aetna probably uses the same claim processing edit if the denials started appearing at the same time as the Medicaid ones so once you get to the bottom of what's going on with the Medicaid claims you can probably apply the same solution to the Aetna claims.

It is possible that the policy really is that you need a denial from the primary to bill the secondary, but this seems weird for vision claims as the benefits are obviously either there or not.

And if you get a strange explanation from anyone at the Medicaid or Aetna offices that doesn't make sense, and they can't point to a policy document that clearly spells out what they're saying, ask to talk to someone else. I run into a lot of insurance call center reps who don't seem to have any idea what they're talking about when I have really specific processing questions like this and I will go ahead and find someone else to speak with or ask to be transferred to someone in the actual claims processing department rather than the provider call center. It can take a few calls before the situation is fully clarified, but in the end you will at least know what's going on and where the policy is if it really exists.

Jul 22nd, 2014 - msmith6243 7 

re: Vision Claims - Improper Denials

What CPT® and dx codes were billed out? If the patients have a medical diagnosis, then I can see why they would want a denial from the primary medical policy before paying.



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