u/Ok-Repair7330

I've been stumped by a recent new client's claim through Medicare who's seeing our practice for individual psychotherapy sessions and was hoping someone more experienced could clock what's going on with this client.

(I've been working in the field for a little over a year and a half for a small practice, but whatever it is I've never encountered before)

We have a Medicare card on file for the client (with Medicare entered as the primary policy) and it shows as active in the Wellpoint Federal portal. However, the initial claim was rejected under code 834, saying "Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor."

Taking a look at what the client entered as supplemental insurance, it's a Molina Medicare Complete Care Plus plan, and the card says it's a HMO D-SNP plan that contracts with Medicare and our state's Medicaid.

We're in-network with Medicare but not Medicaid, and I was under the impression that whenever someone had both, Medicare would be primary and Medicaid would be secondary. That doesn't seem to square with the rejection message or the presumed secondary policy being a HMO plan, which I thought could only be the case with primary policies.

I'd greatly appreciate any help in understanding what's going on here, and if we're out of network despite the Medicare card, I'd like to know where I should have been able to catch this.

Thanks!

I've had okay experiences with UMR before, but something very strange has been going on recently.

For reference, I'm billing for a dietitian, and for a new client the initial claim was rejected saying Z71.3 (dietary counseling and surveillance) isn't considered appropriate as a diagnosis code.

In the past, this has been a simple process to resolve - the provider gives a more specific diagnosis, I request a fax for the claim and call in with the passcode, the representative verifies the diagnosis code would be valid with the plan details. However, this time I've experienced the following:

- Call in with the first passcode, I confirm my name and our TIN, representative 1 stumbles over asking me to confirm the patient name and date of birth, before they can get it out cleanly they hang up on me.

- Call back in, first passcode no longer works.

- Request second passcode, call in, representative 2 immediately hangs up without saying anything.

- Call back in, second passcode still works, I immediately say "Hello" even though I was the one calling thinking the last person might be doing the Gen Z phone thing of not saying anything when they answer. Representative 3 hangs up on me.

- Call back in, second passcode no longer works.

Has anyone else experienced anything like this, and if so did you just have to keep plugging at it until someone took pity on you or what?

Ideally if they knew who was responsible for the calls associated with the one use of each passcode, I'd love to report the people who are stonewalling legitimate inquiries, but I'm assuming there's no mechanism for that whatsoever and their representatives do that because they know they can do it freely.