03/30/2023

BCBSM Auth Limits RESOLVED - NEW Issue Identified K071 Rejection

MSHO Members,

Early last year many of you discovered a problem with authorization approved units rejecting prematurely when multiple claim lines were billed for the same HCPCS codes on the same date of service (i.e., two vials billed to create proper dose or JW modifier code billed to account for waste, etc.).  The Rejection codes applied to this issue were M348 or K074.  As soon as this was reported by multiple practices MSHO approached BCBSM to request an investigation into this potential issue.  BCBSM did confirm this was a system issue and agreed to work with MSHO to provide support while their solutions team identified the problem and provided a solution to prevent these premature denials.  According to BCBSM the solution was deployed on March 3, 2023.  The Solution team has been monitoring the claims since that time and they have confirmed the problem has been resolved. 

Incidentally during this work, a new issue was discovered, the K071 rejection. Some of the MSHO practices reported this rejection and after conversations with the BCBSM team they confirmed there was another system issue causing this rejection.  The cause of this rejection was identified when multiple claim lines were billed for the same HCPCS code, but different NDCs, the first line would pay correctly, but subsequent lines would reject.  The BCBSM solutions teams has identified a fix to the system for this issue as well – scheduled to be in production by the end of April.

What this means for you:

• M348/K074 issue – Any NEW authorizations obtained 3/3/2023 or after will have the auth decrement fix applied. Any claims billed against these new authorizations will process correctly. However, if the authorization was obtained before 3/3/2023, M348/K074 rejections may still occur. Please submit these claims to PRS for reprocessing.  The BCBSM claim adjudicators have been provided with a guideline to follow to have these claims paid.
  
  
• K071 issue – Please submit these claims to PRS for reprocessing. The BCBSM claim adjudicators were provided with a guideline to follow to have these claims paid.

We thank you for reporting these issues to MSHO and we are grateful for the partnership we have with our BCBSM team.

If you have any questions, please contact MSHO at billing@msho.org.