10/16/2019

HIP Prime Denials for RFC Codes 11721, 11056 and 11057 (Denial reason-Member not covered for RFC even if diabetic)

We are getting denials for routine care codes for HIP Prime members, such as CPT codes 11721 and 11056/11057, with ICD-10 E11.49 with B35.1 and L85.1. EOBs state member is not covered at all for routine care, even if diabetic. We're told this is a new policy as of this year. Is the insurance committee aware and what steps are being taken to address this issue. These are often high risk patients, who require regular podiatric care.

This is a case where a commercial plan is not covering the service even though Emblem Plans have typically followed Medicare guidelines on coverage for podiatry services. The insurance committee is actively working to address the changes in coverage to HIP Prime members.

Additionally, we will follow-up with the committee as far as progress being made in response to these benefit reductions for HIP members.