02/21/2019

BC/BS Anthem Plus-Reimbursement Issues for DME

Hello, I am having difficulty getting reimbursed from a Managed Medicaid Plan - Blue Cross/ Blue Shield Anthem Health Plus. It is for Durable Medical Equipment. The device is a Wheaton Bracing System. This is a Pre-Fabricated KAFO component night splint, consisting of Upper (KO) and Lower (AFO) parts. . As such, the manufacturer and coding guides suggest billing L1930 for the Lower (AFO) component and L1836 for the Upper (KO) component. For all insurance plans, including Managed Medicaid, when billing for Bilateral DME, we bill as follows: one line L****, Lt and another line L****, Rt. The same for the Bracing System in question: L1930, Lt (Separate Lines for each) L1930, Rt L1836, Lt L1836, Rt The L1930 line items get paid, as billed. The 1836 line items get denied as "incorrect modifiers". When we call to inquire we are told that we billed with the incorrect modifiers and should bill with the Bilateral procedure modifier 50 ( strange because this is DME and not an actual procedure). We take the insurers advice and then resubmit the claim as follows: L1836 L1836, 50 or L1836, 50 The claim still gets denied as "incorrect use of modifiers"! When we appeal, we get no understandable response and they uphold the denial.

With the knee orthotic component, if the modifiers are changed per the insurance’s request from site modifiers to the bilateral services modifier, they should also confirm how many units of service should be billed on the corrected claim. This rule can vary from insurance to insurance. Some want one unit of service when billed with modifier -50, others may want two for a bilateral service. That detail should be clarified before resubmitting the claim to prevent any further denials and to get this portion of the DME claim paid by Health Plus.