05/04/2021

Correct Billing for Excellus PPO Primary that has no Orthotics Coverage and Medicaid as Secondary

We have a patient who has Excellus PPO plan as primary and Medicaid 2ndary. Patient does not have foot orthotic coverage under the Excellus plan. Will Medicaid pay for orthotics? If not I'm guessing we can not bill the patient for them?

Medicaid does not cover orthotics when they are billed by a podiatrist- orthotics would only be payable if the billing provider is a DME supplier. Even with a denial from Excellus showing patient responsibility, the secondary claim would still be denied due to a provider specialty restriction. The patient would be able to be billed for the orthotics, but only if two conditions were met:

• The patient would need to sign an agreement in advance knowing that Medicaid will not pay for the orthotics and that they agree to accept financial responsibility for the encounter