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Old 03-26-2009, 01:07 PM   #1
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BCBS Appeal - Routine Physical

Hello All,

While googling out on how to do a BCBS Appeal, I encountered this site. After reading several appeal threads here, I think my case is much simpler.

I went to get a Routine Physical in December last year after I validated with BCBS (of Tx) that Routine Physical is covered once per year for each customer. I made sure that the facility performing the Routine Physical was also in-network.

Diagnosis came out as me being obese. Part of the reason why I wanted to get a physical is that no matter how much exercise/dieting I am doing, I am not losing weight. I am on the border line of obese/overweight. BCBS says that my plan (PPO) does not cover diagnosis with Obesity (27800). They asked me to inform facility that I disagree with their diagnosis. Facility denied it out right. I think they are correct.

I don't understand how a procedure which is still covered can be denied based on the diagnosis? I mean unless you do a procedure how can you diagnose any condition?

How do I appeal this? I have the diagnosis from the doctor. I think they have to pay for the physcial. What chance do I have in getting this appeal in favor to me?

Please give any advice you have.

Thanks in Advance

 
Old 03-27-2009, 10:52 AM   #2
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Re: BCBS Appeal - Routine Physical

How did the facility enter the visit - as an annual physical or as a visit with a diagnosis?
That could be the problem. If they files it as an annual, it should have gone thru. I've had problems where the office didn't code the claim submittal correctly and it was denied. They had to run it back thru.

 
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Old 04-01-2009, 05:01 PM   #3
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Re: BCBS Appeal - Routine Physical

Quote:
Originally Posted by rave29 View Post
Hello All,

While googling out on how to do a BCBS Appeal, I encountered this site. After reading several appeal threads here, I think my case is much simpler.

I went to get a Routine Physical in December last year after I validated with BCBS (of Tx) that Routine Physical is covered once per year for each customer. I made sure that the facility performing the Routine Physical was also in-network.

Diagnosis came out as me being obese. Part of the reason why I wanted to get a physical is that no matter how much exercise/dieting I am doing, I am not losing weight. I am on the border line of obese/overweight. BCBS says that my plan (PPO) does not cover diagnosis with Obesity (27800). They asked me to inform facility that I disagree with their diagnosis. Facility denied it out right. I think they are correct.

I don't understand how a procedure which is still covered can be denied based on the diagnosis? I mean unless you do a procedure how can you diagnose any condition?

How do I appeal this? I have the diagnosis from the doctor. I think they have to pay for the physcial. What chance do I have in getting this appeal in favor to me?

Please give any advice you have.

Thanks in Advance
I've been around the insurance rig-a-ma-roll quite often. Insurance can deny based specifically on diagnosis alone. The insurance system is set up to deny claims....think of it that way. There isn't much the insurance doesn't catch. So you have to be smarter than it. Did you make your appointment for a routine physical? I think you said yes...therefore, you need to contact the place of service that you had the physical done. You need to request to them that they change your primary diagnosis on the claim. If obesity is a secondary or tertiary diagnosis it will probably go through the system and pay. But that primary diagnosis HAS to be routine in order for your benefits to post correctly and have the insurance pay. It has nothing to do with the procedure code. The facility was in the WRONG by putting obesity as your diagnosis when you came in strictly for a routine physical. Good luck, and start with the facility to get that changed. Guarantee insurance will pay when you do.

 
Old 04-01-2009, 08:39 PM   #4
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Re: BCBS Appeal - Routine Physical

Hi!

When claims was received by the insurance, the first thing they match was the procedure codes and diagnosis code. If your doctor was billing for the annual physical exam yet the diagnosis code was not preventive. This would definitely be denied. Insurance has the list of their procedure codes and diagnosis code that would fall for preventive services. The provider needs to resubmit the claim changing the primary diagnosis code to preventive ones.But never indicate the 278.00 diagnosis code anywhere in that claim.Providers can do that.if the providers did call the insurance,advised should have been given already to make necessary changes. This is a light case an easy one...

 
Old 07-03-2009, 09:19 AM   #5
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Re: BCBS Appeal - Routine Physical

Also, have it resent as an appeal. If they just simply resubmit the claim even with a different diag. code the computer will/may just simply deny as previously submitted/denied. The people who receive you claim and imput it into the computer don't review the claim, just plug in the numbers and the computer is programed to automatically ajudicate/process it with no decision by an actual person. (that assuming actually people still do this, it may all be done electronically by the company who processes you claims).If the appointment was originally made as a routine physical and dx code was imput improperly, that may be the problem so do an appeal.

Did claims in a past life.

 
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