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CTSS services with UA modifier billing to commercial payers? Success?

crystalp 3 years ago in Billing/Electronic Modules updated by Leah T. 5 months ago 10

Has anyone billed CTSS codes lie H2014 with UA modifier to commercial payers and have had reimbursement success? Or should we just skip billing primary commercial payers and bill directly to MA/PMAP? Have you had to put PR 96 on the COB info since commercial payers do not reimburse those services/codes? Thanks in advance.

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I would verify with the member's primary insurance first.  Some commercial plans will pay for CTSS services with the UA modifier and you should still make a good faith effort to bill their primary before queuing to a PMAP.  Whatever does not get covered by their commercial plan could still count for their patient responsibility and help the family get closer to their deductible too.

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Yes, use the UA mod for all of your CTSS billing.

Some BCBS, PrefOne, Cigna policies pay for services with certain diagnosis.  Also, Medica/UBH just added CTSS codes as payable but they need to be requested to be added to your contract for each supervisor or you will get CO denials instead of PR.

You need to send claims to the private primary payer first before forwarding on to PMAP's with COB info.  You can't just add the PR96/204 to the COB without the private payer actually giving you that info on each claim - unless they give you a blanket denial for services like in a letter.  Health Partners has done this for us in the past, given us a letter covering denials for an entire year.  Then you could do that.

You can bill straight to MA and bypass the private company without putting in any COB info.

Also, with Medica/UBH, if they give you CO denials, call them and ask that they look in the procedural notes and send the claims back to be reprocessed with PR denials.  Kyle Miller at OPTUM, myself, and Paula Dekker @ UBH/OPTUM just rewrote and had passed (at OPTUM's national level of procedures) a new procedure starting 2/1/17 so that the claims should start denying with PR's instead of CO's.  This was mainly due to clients have grant funding as a secondary payer (which Medica/UBH would not see as an active payer source). 


Hope that helps!

Thank you for that info Shauna! I am currently going back and forth with PreferredOne on this very issue. Because they are denying with CO, we can not pass the 90899's onto the secondary payer. I am going to email my contract contact, and ask if we would be able to get a blanket denial for at least this year, so we may submit to the secondary PMAP's.

Yes, and if they don't agree, ask to open up a project with either contracting or a claims director so that their process can get changed to get better denial codes.  That's what we did, it was lengthy (about 8 months), and we had a few writeoffs for timely filing at secondarys that didn't honor the primary's process, but overall it saved thousands in getting those claims reprocessed.

This is the reply I received from PreferredOne:

I have forwarded your emails to our coding department and the following recommendation was given:

“This is a billing scenario that the provider needs to address with AUC since there is no uniformity in reporting of the services to the various commercial payers.  The provider will need to access the MN AUC website, complete an SBAR, and submit it to the address listed.  MDH will then review and determine what TAG (Technical Advisory Group) the SBAR should go to for further review and action. 

I will be following through with the MN AUC website, today. I will post any results here.

If you are a member of a State professional organization, hopefully your organization would be interested in helping out on behalf of the members.

I'm hoping to get some  more input on this topic. We have CTSS clients who have a primary commercial and secondary MA plan. It seems like it is correct for us to bill the same exact code to each payer. That is, bill UA modifiers to the commercial and Medicaid plan for both CTSS H codes and 9 codes. Am I thinking about this correctly? Thanks.

I have been doing some research on CTSS billing to commercial payers and the UA modifier requirement; is it true that the UA modifier doesn't have to be used in CTSS billing to commercial payers or should the UA always be used in CTSS billing even if the payer denies?

We have had success billing H2014 with UA modifier to primary commercial payers.