04/21/2017

Excellus BCBS-Appeal Rights/Clinical Editing Review Request Form & Excellus-Medicare Advantage Plans payments for 97597

Excellus Blue Cross has denied all treatments for 97597 with L97.511, L97521 and E11.42. Denial: Does not follow Medicare guidlines. Excellus stated that this was a change as of 1/1/17. We have found no changes with Medicare. Any suggestions? Thank you

No appeal rights were given by Excellus BC/BS because the incorrect form was used to request a review of the bundled services. As per the insurance’s provider manual, there is a separate form used (see attached) that providers must use if they disagree with a denial from any Excellus Blue Cross product that was denied due to clinical edits (bundling/CCI edits, authorization, medical necessity, etc.). Requests must be sent with the appropriate documentation to Excellus within 120 days from the date of denial in order to have the denied portion of the claim reconsidered. Attached is the section from the provider manual that outlines the protocol for disputing non-payment due to clinical editing (section 7-11 from the manual, attached):

 "Providers who disagree with a clinical editing determination for a procedure code combination may request a clinical editing review. The Clinical Editing Review Request Form is available on the website or from Customer Care. To access the form, visit ExcellusBCBS.com/wps/portal/xl/prv/contactus/printforms/. Submit the form to the address listed on the form. In addition, disputes can be submitted online at ExcellusBCBS.com/ProviderCodingBilling (website login is required). It is important to include any clinical documentation that will support the request. Excellus BlueCross BlueShield will make a determination on the review and notify the provider in writing within 45 days of receipt of all necessary information. Unless otherwise stated in the provider’s participation agreement, Excellus BlueCross BlueShield allows 120 days from the date that the provider received the original claim determination to request a review. Excellus BlueCross BlueShield’s policy is to begin this 120-day time frame for review within five business days after the claim determination was sent to the provider.”

In regards to the issue for the source that Excellus BC/BS is using to determine medical necessity for the Medicare Advantage plan members, CPT 97597 is not specifically listed in this policy, and does not give the guidelines for any other diagnosis other than a decubitus ulcer, which is not the treatment in question. Excellus needs to cite another source for why wound debridements are not being covered since the NCD chapter does not adequately explain why it is not medically necessary.

Until additional action is taken where the Medicare advantage plan will update its policy, the only recourse that the practice would have is to file a clinical editing review to prove medical necessity of the wound care provided. The appeal process does not apply to clinical editing denials. The only way to have this type of denial reconsidered is to use the attached form with all supporting medical documentation to show that the edit is unreasonable and is causing claims to be denied incorrectly.

See links below for attachments:

Excellusbcbsprovidermanual 16updatecombofinalweb

Exclinicaleditingreviewrequestdec2015fillable