Provider refuses to resubmit claim with correct diagnosis codes
I had a EMG and NCV medical test done at a provider that was denied coverage due to inappropriate diagnosis codes being used. This is a test that has a policy requiring specific diagnosis codes to indicate it is medically necessary. I have had the test on a different area of the body before at another provider and it was covered without issue. I have received multiple diagnoses which match the diagnosis codes listed in the policy, however the provider refuses to read the policy nor contact the insurer to receive guidance on how to correctly resubmit and instead insists I must pay the full fee for the denied tests. My insurance through my employer uses a third party to manage patient services instead of allowing me to speak directly to the insurer, and when I opened a case on this with the third party, they have done nothing but request the provider contact the insurer for coding guidance. They also tell me an appeal is likely to be unsuccessful if the diagnosis codes remain incorrect (the provider used a code for tinnitus for example as the indication for the test when it should have been autonomic nervous system disorder and/or numbness and/or tingling). What can I do to get this resolved? I knew my policy and know it is covered for diagnoses I had prior to the testing yet it all comes down to whether the provider will resubmit with coding from the policy. I did everything right here- it’s maddening! For anyone wondering, I have Independence Blue Cross PPO.
submitted by /u/mindysmind
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