55: Procedure/treatment/drug is deemed experimental/investigational by the payer
On Call Scenario:
Claim denied as Procedure/treatment/drug is
deemed experimental/investigational by the payer
↓
May I get the denial date?
↓
(Check insurance payment history if
the same CPT paid by the same insurance)
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as Do you need any additional
payment received for same CPT? document to process the claim?
Claim denied as Procedure/treatment/drug is
deemed experimental/investigational by the payer
↓
May I get the denial date?
↓
(Check insurance payment history if
the same CPT paid by the same insurance)
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as Do you need any additional
payment received for same CPT? document to process the claim?
↓ ↙ ↘
What is the TAT Yes No
What is the TAT Yes No
for reprocessing? ↓ ↓
↓ What document What is the Fax# or Mailing
May I have the is needed? address to send an appeal?
claim# & call ref#? ↓ ↓
How much is the How much is the
time limit to send time limit to send
the document? an appeal?
the document? an appeal?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?
Important Note:
- On this denial, sometimes it is very difficult to get the CPT reimbursed. So, it should be assigned to the coding team to get an alternate CPT code.
- If the coding team provides an alternate CPT code then update the same and resubmit the claim.
- If the coding team replies that there is no alternate CPT code then work as per the rep's suggestion. If insurance needs any additional documents then share the same.
- If insurance does not need any additional documents then you can try with an appeal.
- It is also good to share such CPTs with the client because sometimes they do have an update on whether such CPTs will be paid by the insurance or not. And they advise writing off the CPT directly instead of sending additional documents or appealing if the CPT is not going to pay.
Thanks
ReplyDeletethanks for the information
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