We tried filing under the Rx plan, but since it is not written and filled at a pharmacy, they wouldn't pay and neither will the mental health part. I know that insurance will try to avoid paying for anything that they can for the most minimal of reasons, like you didn't send one piece of info and they won't write and tell you that it was denied or why. You have to make 10000000 phone calls, they want more info and still deny the claim.. Any info would be appreciated!!
Insurance coverage is very confusing and there are sometimes good reasons to not cover certain things. Believe me that I am not defending the insurance company when it comes to not covering things. I am insured by the same company I work for and I myself have experienced the frustration of having things denied that are medically necessary.
The reason methadone clinics are not usually covered is because the patient usually just shows up and gets their medication. They are not generally assessed by a licensed clinician. Allot of times the counselors at a clinic are just that (trained counselors). They have not received extensive education in the field and may actually be psych interns who have not yet completed their education. Methadone can be very dangerous when it is not taken as directed or if the patient doesn't follow the instructions after taking it. It can be important to be under the supervision of a licensed health professional to make sure that there are no serious side effects... etc. That being said if you cannot find a way to get it covered you may be able to find an outpatient chemical dependency program that administers methadone and that could be reimbursed by your insurance or you may be able to find a psychiatrist that is willing to work with your husband on an outpatient basis and would perscribe the methadone.
I really wish you luck on getting some of the cost reimbursed to you. If your husband is seeing a licensed therapist or psychiatrist at the clinic let me know the counselors name and I will look them up in our database to see how they are licensed. Also if you could let me know how long they are seeing your husband during each visit. If it sounds like something that could meet our standards I will send you the revenue codes and you can try to get some of the cost reimbursed. I know how much of a burdon the cost of treatment can be and how beneficial it is to your lives.
That being said...Gemini, I think I can help you if you would like to post your e-mail. I can contact you and give you more information.
1. Facility will provide multidisciplinary program of at least 3 treatment hours per day at least three times per week; the frequency may be decreased as clinically indicated.
2. Multidisciplinary assessment with an individualized treatment plan which addresses psychological, social, medical, cognitive, and substance abuse needs.
3. To be seen by a psychiatrist by the third day of attendance.
4. Monitoring of psychotropic medications
5. Family assessment and therapy by a licensed behavioral health provider.
6. Discharge planning is initiated on the day of admission and includes appropriate continuing care plan.
Also... I never said a patient "just shows up and gets medicine". I happen to know several people who work at methadone clinics in CA as "drug counselors". They are not licensed as a therapist or psychiatrist. In fact they are often times psych interns or students who have not completed their clinical hours to get their license as a therapist or social worker. Allot of health insurance companies do not pay psych interns or drug counselors. Yes they are educated and trained in the field but they DO NOT hold the required license and therefore cannot be reimbursed. I am not at all saying that they are not qualified to assess patients or that they are not working directly under a licensed provider. I am simply saying that more often than not an insurance company will not reimburse this type of clinician. I am not saying it is right or that I agree with the way that insurance companies handle the situation. Like I said before. I work for an insurance company who has denied my own claims. I am just giving you my perspective. I do not specialize in substance abuse. I have never worked for a methadone clinic and I do not know the specifics of how things work at these clinics. I was giving some suggestions on how to get the claims paid. Because working for an insurance company (in the behavioral health department) I see claims denied and paid all of the time. I happen to know that a claim can be submitted, denied, and then resubmitted with different coding and paid. There are so many details that are important to figure out whether or not this can be reimbursed. It all depends on whether the methadone is being prescribed for pain management or substance abuse. It also depends on what type of policy you have. Every policy is different and allot of policies do not cover substance abuse treatment. So without knowing the specifics it is hard to know how exactly to get this paid. I never said that I was an expert on methadone clinics.
I apologize if anything that was stated in my previous post was offensive to anyone. Obviously I do not know the specifics of methadone clinics other than the insurance company I work for does not normally reimburse payment for treatment there. I just know that there are ways that you can bill things to at least get some of the money reimbursed to you. Depending on what type of provider is being seen a superbill could possibly be submitted to at least request reimbursement of the office visits as long as they took place with a therapist or psychiatrist. Obviously this will not cover all of the costs but since these visits and medications have been paid for out of pocket it may be nice to at least get part of it reimbursed.
Any information is helpful. My husbands cousin has the paperwork and is going to take a look @ it and she used to work for BCBS and knows someone who still works there, but the more info I have, the better off I am! Thanks for the replies!! :D
**this post is edited by moderator *** *** private e-mails not allowed **
Kelly, you did say in your post that it is not usually covered bc a person shows up and takes their medicine. Maybe you should re-read what you typed. I am not trying to be confrontational, but you did say that.
Anyway, he is seen by an MD and his counselor has a degree. The CPT code they gave me was 90782 and diagnosis code is 304.0. Is that helpful to anyone, that is interested in helping me?
We have filed the claim, I sent it by mail yesterday. So, I guess I will find out soon enough if they are willing to pay, so I will repost as soon as I get notification.
Thanks for reading my post!!
June 15, 2010
To: CareFirst BlueChoice, Inc.
Attention: Claims Department
Patient’s name: jollygemini
Patient’s DOB: 05-26-1978
This document contains itemized billing for jollygemini, who is an active
client of New Horizons Health Services, Inc. paying weekly a fee of $85.00 in cash. The
CPT Code is H0020 and Diagnosis Code is 304.00 for billing purposes. This letter is to
inform you that the client bill from MARCH 2010 until MAY 2010 has been paid in full
amount ($1105.00) to New Horizons Health Services, Inc. If you have any questions
regarding jollygemini's billing, please do not hesitate to contact our office.
Below are the dates of services for billing purposes:
Preview of bill:
W/E 03/ /10= 0.00+85.00 = 85.00
W/E 03/ /10= 85.00+85.00 = 170.00
W/E 03/ /10= 170.00+85.00 = 255.00
W/E 03/ /10= 255.00+85.00 = 340.00
W/E 04/ /10=340.00+85.00 = 425.00
W/E 04/ /10=425.00+85.00 = 510.00
W/E 04/ /10= 510.00+85.00 = 595.00
W/E 04/ /10= 595.00+85.00 = 680.00
W/E 04/ /10= 680.00+85.00 = 765.00
W/E 05/ /10= 765.00+85.00 = 850.00
W/E 05/ /10= 850.00+85.00 = 935.00
W/E 05/ /10= 935.00+85.00 = 1020.00
W/E 05/ /10= 1020.00+85.00 = 1105.00
To get reimbursed by filing a claim (if like myself, you have a PPO but your clinic is O.O.N.): download the claim-form online. Fill it out. Then you must get an itemized bill from your clinic. You might have to pay for it ($20). It should look like this:
To:CareFirst BlueChoice, Inc., Attention: Claims Department.
Patient NAme, DOB, Subscriber ID
Provider Info: Name, Tax ID, Address
This document contains itemized billing for Mr. X, who is an active
client of XX Health Services, Inc. paying weekly a fee of $85.00 in cash. The CPT Code is H0020 and Diagnosis Code is 304.00 for billing purposes. This letter is to inform you that the client bill from MARCH 2010 until MAY 2010 has been paid in full amount ($1105.00) to XX Health Services, Inc. If you have any questions regarding Mr. X's billing, please do not hesitate to contact our office.
Below are the dates of services for billing purposes:
Preview of bill:
W/E 03/ 7/10= 0.00+85.00 = 85.00
W/E 03/14 /10= 85.00+85.00 = 170.00
LIST EACH WEEK LIKE THIS, I JUST SKIPPED THE MIDDLE PORTION!
W/E 05/ 2/10= 935.00+85.00 = 1020.00
W/E 05/ 9 /10= 1020.00+85.00 = 1105.00
I live in Maryland. I'm sorry if the rules are totally different in N.C. I know methadone in New Jersey is 100% FREE. Public funding has huge benefits over private clinics trying to profit off of addicts. Actually, most counties in MD will provide Medicaid coverage for those who can't afford methadone. Did you check with your County MEntal HEalth and Hygiene (or just HEalth Dept.)? I'm not poor, I have BC/BS from work, but paying for my methadone upfront out-of-pocket has me living paycheck to paycheck.
Please feel free to ask me anything you can think of, really. My friend works in billing for a clinic, and she knows the good, the bad, and the ugly. I'd be happy to run a few questions by her. Good Luck!
EVERYONE JUST SHOWS UP AND GETS THEIR MEDS. This is after the initial history, physical and counsel phase. I don't know where you are, but in All the clinics I have reviewed, that IS the case. The only exceptions is if the patient is intoxicated by something, or on hold by their counsel person. I don't know why the truth insults you. This reply is to "guest".