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Thursday, July 22, 2010

Non covered service denial - PR 96 and CO 50

PR 96 N115  Non-covered charge(s).

This decision was based on a Local Coverage Determination (LCD). The LCD provides a guide
to assist in determining whether a particular item or service is covered. A copy of this policy is
available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the
contractor to request a copy of the LCD.

CO 50 These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.

This decision was based on Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.


Billing for non-covered services Guideline from BCBS

In the event that BCBSTX determines in advance that a proposed service is not a covered service, a physician or other professional provider may inform the member/subscriber in writing in advance of the service rendered. The member/subscriber must acknowledge this disclosure in writing and agree to accept the stated service as a non-covered service billable directly to the member/subscriber.

To clarify, if you contact BCBSTX and find out that a proposed service is not a covered service, you have the responsibility to pass this along to your patient (our member/subscriber). This disclosure protects both you and the member/subscriber. The member/subscriber is responsible for payment to you of the non-covered service if the member/subscriber elects to receive the service and has acknowledged the disclosure in writing.

Reminder — Contracted providers must file claims

As a reminder, providers must file claims for any covered services rendered to a member, spouse or covered dependent enrolled in a Blue Cross Blue Shield of Texas (BCBSTX) health plan. You may collect the full amounts of any deductible, coinsurance or copayment due, and then file the claim with BCBSTX. Arrangements to offer cash discounts to an enrollee in lieu of filing claims with BCBSTX violate the requirements of your provider contract with BCBSTX.

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