If I’m seeing a PPND – Z39 code (claims payment review code) from Aetna on a claim do I need to reach out to my doctor to make sure they have sent the necessary material to my insurance company?
Background info: I (M 26,) recently had a knee anthroscopy to repair my ACL and a meniscus repair; my surgery was at a Vancouver, WA surgery center and I live in Portland, OR.
The current issue:
I was recently going through my insurance claims on my account when I saw this message on my claim for my surgery:
Claim has been pended for claims payment review. We need your provider to send us current history and physical, clinical records, and operative report (if this applies) to support billed services. If the clinical records contain photos, copies should be provided as originals will not be returned. We will make our decision within 15 days of getting the information. We’ll deny this claim if we do not get this information within 45 days from the day you receive this form. The basis for the denial will be that we do not have the information we need to consider this charge. For claims sent from Texas: Your claim may remain open if we do not get the information. This does not apply to Federal Plans. For claims sent from North Carolina: you have 90 days to send us the information. If we don’t get it, the claim will be denied. This does not apply to Federal Plans. To ensure proper identification and tracking of this claim, you must include: the complete member name, complete patient name and the Member ID number. Please attach this information to this document and return to us. [PPND – Z39]
My question is what is the best way to resolve this matter? I still have ample time since I got this notification, but I was curious if I should be reaching out to my surgeon/care team to get them to send my insurance the relevant information; I’m honestly suprised this information never got sent to them in the first place. So should I be hounding them to get it sent over because I got this, should I be contacting my insurance to confirm they have actually recieved the information but found it insuifficent, or something else?
Any advice would be greatly appreciated!
