TessaLasky 6 years ago in Industry News/Discussion updated by sarah 6 years ago 3

Hello all!

I am having issues with one specific client who has a UHC private and DHS secondary. We are billing IOP services. The UHC denied for medical necessity up front but since DHS covers our services, we figured they would just be billed as secondary, especially since we had that physical denial.

The EOB's have been coming back from UHC stating "contractual obligation" instead of "patient responsibility." Due to this, secondary will not pay.

Has anyone else had this issue? Do you have any solutions?


I spent a year working with DHS on this issue. The AUC has made a recommendation that commercial plans deny with a PR as opposed to a CO, but not all are adhering to that recommendation. We were able to get PreferredOne to deny with a PR on most codes, but they are the only one, so far.

If you get a letter from UHC, stating that they do not cover the specific code for that specific client, and get that information to DHS - they will reprocess the claim and pay it. They will not reprocess it without some form of documentation from the primary payer stating that they don't cover that specific code.

If you contact DHS' Help Desk, maybe they will change their policy. If enough of us let them know this is an issue, perhaps they will change their process on these issues. They SHOULD be just paying these charges, because the clients have the coverage through them, but it seems to be an issue of each payer having their own process "rules" and the clients end up stuck in the middle.

I did contact Amy Klobuchar, but got back a generic health care reform email response. I sent back a reply, but that was three months ago and nothing else has come back.You also have the option of filing a SBAR in regard to UHC's processing of these claims. That is how I was able to get PreferredOne to change how they deny the CTSS codes.

Yes, we have this issue also and worked for well over a year on it with Optum to deny as PR instead of CO.  It is written into their policy nationally as it was a task driven by Kyle Miller at Optum.  But unfortunately Claims still hasn't gotten that message.

We still are receiving those denials but at times Customer Service will send back to have them reprocess, and other times we need to appeal the claims or call Optum directly to have them troubleshoot this.  

A few weeks ago we also contacted the MN Department of Commerce, Parity review and also received the following resources (they are now aware this is happening and I encourage you all to call them for assistance so we can really get this changed):

Here are the resources I promised. These are general resources for clients; however, you can contact any organization to report systematic problems.

  • For mental health coverage or issues causing issues/days for clients who need necessary care and the clients have health insurance through an employer, particularly a larger employer: U.S. Department of Labor:  https://www.askebsa.dol.gov/Webintake/Home.aspx  or call  866-444-3272.
  • For issues involving mental health insurance coverage or related programs:  https://parityregistry.org/share-your-experience
  • For Minnesota clients accessing mental health care through public managed health care organization programs/Medical Assistance programs, contact the Minnesota Department of Human Services Ombudsman:  651-431-2660

Thank you! I will be following through on this, as per your suggestion. I agree - if we all contact them, perhaps we will institute change!