BCBS Waiver Denials

TessaLasky 7 years ago in Industry News/Discussion updated by sarah 7 years ago 5

I was wondering if anyone else was having the same problem and if there were any suggestions on our end for this. Recently we have had two different kids have skills (H2014) deny because according to the representatives at Blue Cross PMAP "there is a waiver that the policyholder did not sign."

What does this mean? Who would then be responsible? Since it is a PMAP plan and the child has active MA, we are unable to bill the parents for not signing a waiver. If they did in-fact not sign a waiver, why would only the skills deny and not other IOP services that the child was receiving?

If the PMAP denies, we try MA. They should cover what the PMAP does not, when the client is active. Will BCBS allow the parent/guardian to sign the waiver after-the-fact?

Thanks Sarah,

How are you able to bill MA as secondary to the PMAP? If we do this, MA just denies for there being an active PMAP as they have a contract that the PMAP is responsible for payment?

As for the guardian signing the waiver, I have called BCBS on this multiple times and every time they say that a waiver was not signed and when I ask questions about it they say that is all of the information they have, then they continue to repeat that the waiver was not signed. I thought it was just the one rep I spoke to but I have called at least 3 times to get the same answer from each rep.

If you have the denial from BCBS, you should be able to submit to MA. They may deny - but you can always then call and plead your case and hope they will send it through. It is time-consuming, but it is a service covered by the plan so it SHOULD be paid. It can take months, just to warn you. 

If the guardian calls, are they able to get another copy of the waiver? When parents find out services may cease, they generally are willing to contact the payer to rectify the situation.

I have another take on the original question.  It is not clear what the actual "waver" form is that is the problem - but in the past I have had many situations in which the policy holder has been sent a "coordination of benefits" form, and if they don't sign it every thing grinds to halt - and claims are denied.  The policy holder often does not open the letter or does not understand what they are being asked to sign.  This occurs when the policyholder has, or may have, two policies and the companies need to coordinate benefits.   The solution in the past has been to ask the policy holder to call the insurance company, which usually results in the form being resent, and getting signed. But, this form is not, I think a "waver."  I am throwing this out as a possible explanation for the denials.

Have you tried having the policy holder call the company to see if they can get it worked out?

In regard to resubmitting a claim to MA that has been denied by PMAP, that seems to be a long shot - they both are, at one level, MA.  In my experience, if the policyholder has a PMAP contract then MA (MCHP) has been very strict about forcing me to deal with the PMAP company.

Yes, that is generally what happens - MA insists you deal with the PMAP. We had an issue when we started our ARMHS program. UCare and HP PMAP would not cover the H2017 codes - so we had to all billing through MA. It was arduous, but MA had to pay because the client had the coverage.