Outpatient Radiology Claims with PA from MedSolutions: Process and Reprocessing

The Process:

There are times when a provider has received approval for a higher level of service in a group of services, yet at the time of the procedure has determined that a less complex service from that group was more appropriate. For example, approval is received for a CT without and with contrast. The radiologist determines that the CT without contrast is sufficient. Prior to NCTracks the “without contrast� code was paid. Now they are denying for no PA.

From now on, providers must call MedSolutions Intake line (1-888-693-3211), and update any authorization where the services rendered were different than authorized.

Reprocessing for this one time exception:

Outpatient radiology claims with codes for these less complex services through dates of services of April 29, 2014, will be paid as part of a reprocessing effort. If you have any questions on this process change, please contact MedSolutions. (NCTracks and MedSolutions will continue to work together in reviewing the post-April 29 claims and additional information will be posted at a later date.)

MedSolutions conducted an audit of these pended claims and was able to identify valid authorizations in their system for many of them. These claims will be adjudicated in the July 22 checkwrite and will appear in a separate section of the paper remittance advice (RA). However, there is no unique EOB associated with this reprocessing.

The 835 electronic transactions will include the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)

For the other claims not paid, MedSolutions has determined that 1) an authorization was not obtained, 2) the authorization was for a different procedure, or 3) the authorization was denied as inappropriate. (Note some of these claims may represent a duplicate claim that was previously paid). MedSolutions has prepared a detailed report of these audit findings and will be mailing those shortly to the address of the Billing NPI for affected providers.

Once providers receive the report, if they believe they had an approved authorization from MedSolutions for any denied claim, please contact MedSolutions’ Client Services department by sending an email to Client.Services@Medsolutions.com. Please include the authorization number for the claim to help expedite the research and resolution.