Rank: New Member
Joined: 3/1/2013(UTC)
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We've recently ran into Anthem only allowing minimal amount for this device(S8262).
$24 to be exact. They are telling us that this is the "allowable amount" for this procedure code. They will not cover the D7880. What options do we have at this point to help our patient get some benefit? Obviously over the phone we were told that benefits exsisted and were payable at 100% of UNC.
Thank you for your time
Julie
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi Julie!
Wow - that is a pretty low allowable amount for S8262. We understand how that can be frustrating and misleading when attempting to estimate the out of pocket expense for your patients!
My suggestion would be to write the insurer a letter explaining why you feel the allowable amount is set too low. If you have examples of average lab fees your office pays for the orthotics, or better yet examples of higher allowed amounts from other insurers for S8262, that would really help your case!
The letter can be a simple:
"We noticed your allowed amount for S8262 is very low - and very low in comparison to other insurers in the area, for example XXXXXXcare allows $150 for S8262, in comparison to your company's allowed amount for S8262 set at $24. Given this information, we ask that you reassess your allowed amount amount for S8262 and re-process our claim at an more appropriate amount if you see fit."
Hope this helps! Please let us know if you have any further questions
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Rank: Advanced Member
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Hi Julie, Great input, Courtney! That is low! I think that D7880 would even pay higher and the insurers usually pay a lower amount than the S8262 on that. Most insurers have been realizing that S8262, Mandibular orthopedic repositioning device, each, is a service not a boil and bite over the counter $24 piece of plastic. By the way, no general fee range has been set for that code. Many insurers are paying a fair fee for this oode which is closer to the fee for a TMD appliance. I would also let them know that the service involves not only a much larger lab fee than that, but also includes the care, skill and judgement and is for a diagnosed disoder for which the doctor is responsible for continuing care. I'm sure you have sent your SOAP notes of medical necessity. You could also rebill it under an unspecified code with report. Hope this helps! Rose Edited by user Thursday, March 7, 2013 3:48:08 PM(UTC)
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