COBGC Payer-Specific Guidelines 3

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?

Accepted Answer

Claim will be denied for lack of preauthorization

Answer

Claim will be paid at a reduced rate (50%)

Answer

Claim will be paid in full because it was medically necessary

Answer

The patient is automatically liable for the full charge

Question 2

UnitedHealthcare's clinical policy commonly requires what documentation before approving a laparoscopic hysterectomy for abnormal uterine bleeding?

Accepted Answer

Documentation of failed conservative treatments such as hormonal therapy and/or endometrial ablation

Answer

One failed medication trial and a normal pap smear

Answer

Only the ICD-10 diagnosis code for AUB

Answer

A second surgical opinion letter

Question 3

Under most commercial plans, how is the global obstetric package typically handled when a patient switches insurance mid-pregnancy?

Accepted Answer

Services are prorated between both insurers based on dates of service

Answer

The first insurer pays the entire global package

Answer

The new insurer covers all remaining care from the effective date of new coverage

Answer

The provider must refund the first insurer and re-bill the second

Question 4

An Aetna member receives an out-of-network cesarean delivery due to an emergency. How will Aetna most likely process this claim?

Accepted Answer

Pay at the in-network benefit level because it was an emergency

Answer

Deny the claim entirely because the provider is out-of-network

Answer

Pay at the out-of-network rate, leaving a larger balance for the patient

Answer

Require the member to file a separate appeal before any payment is made

Question 5

Blue Cross Blue Shield plans often use which concept to bundle related gynecologic services performed on the same day, preventing separate billing?

Accepted Answer

Claim bundling or 'same-day surgery' bundling policies

Answer

Mutually exclusive edits (MUEs)

Answer

Medically Unlikely Edits (MUEs)

Answer

Advance Beneficiary Notices (ABNs)

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?

Accepted Answer

Coordination of Benefits rules were applied because the patient has more than one insurance policy

Answer

The claim was denied due to a coding error

Answer

The claim was paid under a global obstetric contract rate

Answer

The provider is not credentialed with this payer

Question 7

When billing a commercial payer for a vaginal delivery with an episiotomy repair, how is the episiotomy typically handled?

Accepted Answer

Bundled into the vaginal delivery code and not separately billable

Answer

Billed separately with CPT 59300 and a multiple-procedure modifier

Answer

Billed with a -22 modifier for increased complexity

Answer

Billed only if the repair took longer than 30 minutes