05/12/2022

Healthfirst Denial for CPT 99203-Coordination of Benefits

Patient has a HealthFirst Managed Medicaid Plan. It was billed for 99203-25 and 29540-RT. 29540 was paid; 99203 was denied with code: 1H other insurance EOB required. When we called HealthFirst with questions, the answer was to submit claim to HIP and patient ID was provided. When we looked up eligibility and later called HIP, the patient was not found in the system. The ID provided was in fact a Group number listed for this patient on HealthFirst website. What else can we do?

If a claim was denied for coordination of benefits, a provider needs to bill the insurance that is listed as the primary. However, if it has been confirmed that the coverage in question was not in effect on the DOS or if the coverage was invalid, the patient would need to get involved to fix the issue with HealthFirst. The member would need to contact member services and provide the termination date of their other insurance coverage with Emblem Health/HIP so the managed care plan can be listed as the primary insurance for the DOS. Until the policyholder contacts HealthFirst to correct the discrepancy, they will not adjust the entire claim to pay as the primary payer. The insurance will only make corrections to their eligibility file with input from their member, this information will not be accepted from a provider. The patient should be contacted as soon as possible to have them contact HealthFirst, with balance billing the patient as a last resort if they are non-compliant to responding to phone calls or other attempts to reach out to update their COB file.