Dear Provider,
HNS has recently became aware that certain MedCost groups who use Zelis, a claims editing company, (e.g., MedCost Benefit Services and ACS) implemented an edit for CMT codes, which has resulted in the denial of 98941 and 98942 on some MedCost claims. While HNS was not made aware of this edit in advance as we should have been, as soon as we learned of its existence, we immediately reached out to both MedCost and Zelis for more information.
While we are still in the process of learning pertinent details concerning this edit, the following is what we currently know:
According to Zelis, this edit will deny CMT codes if Dx codes in Box 21 and Dx pointers in Box 24E on claims do not support the level of CMT code reported.
The remark code denying the service will appear on your HNS remittances as:
“150 Payer deems the information submitted does not support this level of service.”
In other words, when billing 98941, your Dx pointers must point to Dx codes clearly indicating 3-4 spinal regions, and when billing 98942, they must clearly indicate 5 regions.
Importantly, please know that HNS has identified several claims which adhere to this new requirement but still have been inappropriately denied. We have been diligently working with MedCost/Zelis to resolve this issue and will advise you once a final resolution has been reached.
In the meantime, please note the following:
- Corrected Claims: If a denied claim did not report the appropriate diagnosis codes and/or diagnosis pointers to support the levels (regions) of service for 98941 or 98942, you should make the appropriate revisions and submit corrected claim(s) to HNS.
- Appeals: If the claim reported the appropriate Dx codes and Dx pointers to support the levels (regions) of service for 98941 or 98942, Zelis is currently advising that you should submit an appeal. However, HNS has advised Zelis/MedCost that this is an unacceptable solution for our providers that have correctly reported services and has requested a more appropriate solution.
That said, you may file an appeal of denials of 98941 or 98942 that were correctly billed and incorrectly denied if you so choose. To do so, compose a letter explaining why the manipulation should be allowed and reference the patient name, date of birth, ID number, date(s) of service and the Zelis claim reference number. to obtain the Zelis claim reference number, please contact your HNS Service Representative. Fax the letter of appeal and any supporting documentation, (i.e., patient exam findings, treatment plan, and office notes for the affected date(s) of service) to Zelis Appeals at (855) 787-2677.
Please note that appeals must be received by Zelis within 90-days of the adjudication date.
In closing, HNS fully understands the frustration over the inappropriate denial of claims which are appropriately billed, and we will continue to work with Zelis/MedCost to address these denials and email the HNS Network once a final resolution has been reached.
If you should have any questions, please do not hesitate to contact your HNS Service Representative.
Sincerely,
HNS