Medicaid glitch and other answered questions

I was told by other billers this morning (thanks Christy and Sue) that Medicaid is denying claims that require an authorization even if the authorization is on the claim. In particular, OT/PT claims that require it after the 2 hours each month. DCH and reps have been contacted.

I've been asked the following questions lately, so thought I would share the answers with everyone here...

Evaluations can be/should be performed 2x a year for any insurance company. Many commercial insurances will pay for 2 evals per year, and as often patients change insurances, it's a good practice to follow so you're ready if that happens.

Modifiers for claims The following modifiers are often referred to as federal modifiers:

GT, GN, GO, GP, HA, U1, U8

However, UHC and Humana like to use these modifiers as well.

For commercial insurance claims (except UHC and Humana), 95 is used for telehealth claims. This past year to reduce confusion, most insurance companies allowed both 95 or GT on claims.

CMOs not paying up the full Medicaid rate as a secondary:

Another biller (Sarah thank you!) passed the info along that to fix this issue, make sure you realize how your software is reporting the RC coding to CMO. If it is stating that only a copay is needed, then the CMO will only pay the copay (or whatever allotted amount is stated if not meeting the Medicaid rate).

Remember also if you are in BCW and unfortunately have a contracted rate of less than Medicaid standard rate with a CMO, BCW can be billed for the difference.

Lastly, the long-awaited news of Peachstate taking over Wellcare has been announced with the date of 5/1/21. Still don't know the rates, how this will work, so hopefully someone will hear soon.