12/07/2016

Process for Billing Secondary Insurance for S0395 After Rejection from Noridian

We received a front end rejection from Noridian (Jurisdiction A) for code S0395 (2 lines of coding) RT and LT modifiers. The rejection code was: A7:507 for both lines and A3:247. L3000 was billed (2 lines of coding) as well on same claim. Of course the whole claim was rejected because of the S0395. The pt's secondary insurance is "The Empire Plan" (United healthcare). "The Empire Plan" reimburses code S0395. We will need a PR rejection from Noridian before it can go to pt's secondary so they can pay this claim. Can we even bill claim through Noridian first? Do we have to forget getting paid on code S0395? Can we just bill S0395 to "The Empire Plan" separately from code L3000 and get reimbursed?

A portion of this claim should not be submitted to Noridian for processing- HCPCS code S0395 should be submitted to NGS Medicare for processing. Once the carrier processes and denies the casting charges for the orthotics, the patient responsibility can then be forwarded to the Empire Plan for payment according to their fee schedule.

The orthotics billed under HCPCS code L3000 should be billed to Noridian Medicare for processing and should process to deny as an excluded benefit that can be billed to the Empire Plan for payment as secondary.