Has anyone else seen denied claims from BCBS pmap (LMN... policy) and been told it is because the member is in a Restricted Recipient Program?
This note is from MNits regarding this type of policy/program:
Restricted Recipient Program:
Some MHCP recipients are required to receive the following services from specific providers: Inpatient Hospital, Pharmacy, Physician Services, Mental Health, Outpatient.
The frustrating thing is that you do not know the member has this "restriction" unless you actually call BCBS or first check Availity and then check MNits. It is NOT indicated on Availity at all. So when a client gives you their BCBS pmap card and you check Availity for active coverage, you then have look at the image of the card to get their MA #, then login to MNits to see if they have this type of program.
Also, the BCBS rep told me authorization is NOT an option for this type of program and our only option for possible payment would be to appeal for medical necessity.
Help anyone! Thanks, Sara
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