Forum - Questions & Answers

Aug 26th, 2015 - LBAROGIANIS 250 

UHC DENIALS CO-234 AND CO-243 for Surgery claims

Is anyone out there getting these denials from UHC and affiliates? This is the scenario: Pateint goes to hospital, gets admitted, hospital calls us for consult, the physician decides surgery is needed. Hospital obtains authorization for stay. Then we bill to UHC, they pay on certain codes and then deny certain codes. Never requested records. So the claim is partially paid. The hospital gets paid and they want us to appeal. Why should I appeal a claim that the hosptial has authorized the visit? Do they now expect the on call surgeons to get auth? See denial below: Anyone out there experiencing this?

234: This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the
NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
243: Services not authorized by network/primary care providers.

Aug 26th, 2015 - guldemdpa 1 

re: UHC DENIALS CO-234 AND CO-243 for Surgery claims

We have been getting a very high amount of denials from UHC for missing precertification. Dr is a hospitalist/Internal Medicine and admitting/attending. Patients come in through the ER and are admitted to her. I do not have any problems like this from any other insurance. I believe the UHC mantra now is to deny what they can get away with and hope you don't appeal. My next step is to complain to the Texas Insurance Board.

Aug 26th, 2015 - LBAROGIANIS 250 

re: UHC DENIALS CO-234 AND CO-243 for Surgery claims

Is the hospital trying to obtain authorizations for these admits? I have appealed a few explaining that our physician has no control over the hospital admissions departments. Most patients have a clause in their policy regarding emergency admissions do not require authorizations. I have billed the patient to get them involved for help. I mean if UHC thinks that we are going to eat these services as they get fatter.. they can forget it. They sent me a spreadsheet to fill out for a so called claims project. Hopefully, they will tell me why this is going wrong. These new plans that they are developing are making harder and harder for us to get paid. I mean seriously, do they need every physician calling them to get an authorization during a hospital stay?

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