COBGC Payer-Specific Guidelines 3 — Questions and Answers
Question 1: A patient's commercial plan requires preauthorization for a hysteroscopy with polypectomy. The surgeon performs the procedure without obtaining auth. What is the most likely outcome?
- Claim will be paid at a reduced rate (50%)
- Claim will be denied for lack of preauthorization (Correct answer)
- Claim will be paid in full because it was medically necessary
- The patient is automatically liable for the full charge
Correct answer: Claim will be denied for lack of preauthorization
Commercial payers will typically deny a claim outright when a required prior authorization was not obtained, regardless of the medical necessity of the procedure.
Question 2: UnitedHealthcare's clinical policy commonly requires what documentation before approving a laparoscopic hysterectomy for abnormal uterine bleeding?
- One failed medication trial and a normal pap smear
- Documentation of failed conservative treatments such as hormonal therapy and/or endometrial ablation (Correct answer)
- Only the ICD-10 diagnosis code for AUB
- A second surgical opinion letter
Correct answer: Documentation of failed conservative treatments such as hormonal therapy and/or endometrial ablation
UHC and most major commercial payers require evidence that conservative, less-invasive treatments have been attempted and failed before approving hysterectomy for AUB.
Question 3: Under most commercial plans, how is the global obstetric package typically handled when a patient switches insurance mid-pregnancy?
- The first insurer pays the entire global package
- The new insurer covers all remaining care from the effective date of new coverage
- Services are prorated between both insurers based on dates of service (Correct answer)
- The provider must refund the first insurer and re-bill the second
Correct answer: Services are prorated between both insurers based on dates of service
When a patient changes insurers during pregnancy, each insurer pays for the services rendered during its coverage period, requiring the global package to be unbundled and billed by date of service.
Question 4: An Aetna member receives an out-of-network cesarean delivery due to an emergency. How will Aetna most likely process this claim?
- Deny the claim entirely because the provider is out-of-network
- Pay at the in-network benefit level because it was an emergency (Correct answer)
- Pay at the out-of-network rate, leaving a larger balance for the patient
- Require the member to file a separate appeal before any payment is made
Correct answer: Pay at the in-network benefit level because it was an emergency
Federal law (and most state laws) require commercial insurers to cover emergency services at the in-network benefit level, regardless of whether the provider is in-network.
Question 5: Blue Cross Blue Shield plans often use which concept to bundle related gynecologic services performed on the same day, preventing separate billing?
- Mutually exclusive edits (MUEs)
- Medically Unlikely Edits (MUEs)
- Claim bundling or 'same-day surgery' bundling policies (Correct answer)
- Advance Beneficiary Notices (ABNs)
Correct answer: Claim bundling or 'same-day surgery' bundling policies
BCBS and other commercial payers apply claim bundling policies that combine multiple related procedures performed on the same day into a single allowable, preventing double-billing.
Question 6: A commercial payer's explanation of benefits (EOB) shows a 'COB adjustment' on a claim for an OB delivery. What does this indicate?
- The claim was denied due to a coding error
- Coordination of Benefits rules were applied because the patient has more than one insurance policy (Correct answer)
- The claim was paid under a global obstetric contract rate
- The provider is not credentialed with this payer
Correct answer: Coordination of Benefits rules were applied because the patient has more than one insurance policy
A COB adjustment on an EOB means the payer has applied coordination of benefits rules because the patient has dual coverage, adjusting payment based on what the primary payer already paid.
Question 7: When billing a commercial payer for a vaginal delivery with an episiotomy repair, how is the episiotomy typically handled?
- Billed separately with CPT 59300 and a multiple-procedure modifier
- Bundled into the vaginal delivery code and not separately billable (Correct answer)
- Billed with a -22 modifier for increased complexity
- Billed only if the repair took longer than 30 minutes
Correct answer: Bundled into the vaginal delivery code and not separately billable
Episiotomy and its repair are considered integral to the vaginal delivery procedure and are bundled into the global obstetric or delivery code by virtually all payers.
COBGC Payer-Specific Guidelines 3
A patient's commercial plan requires preauthorization for a hysteroscopy with polypectomy.
The surgeon performs the procedure without obtaining auth.
What is the most likely outcome?