Apr 17, 2011 | Medical billing basics
Adverse Determination Appeals A provider may file a written request with BCBSF for reconsideration of a denial of payment because a proposed, or actual, health care service or supply was not medically necessary, was experimental or investigational, was supportive of...
Apr 15, 2011 | Medical billing basics
Modifier 54 54 Modifier Surgical Care Only: One physician performs a surgical procedure and another provides preoperative and/or postoperative management. The Medicare Physician Fee Schedule Database (MPFSDB) gives percentages that apply to pre and intraoperative...
Apr 13, 2011 | Medical billing basics
A Utilization Management (UM) Appeal is defined as a written request from a provider to review a claim that required an authorization or precertification affecting a claim’s payment. This does not include provider appeals of pre-service determinations (unless required...
Apr 13, 2011 | Medical billing basics
DESCRIPTION OF THE ISSUE Provider’s TIN# was linked with the individual provider name but it should be linked with the Group name as Prime Hospitalists Group. So the claims that were filed with individual name was processed under Out of network....
Apr 10, 2011 | Medical billing basics
The Billing Dispute External Review Process (BDERP) will provide for a Billing Dispute External Reviewer (BDER), to resolve disputes with physicians and physician groups arising from covered services provided to BCBSF’s members by such physicians and/or physician...
