Preventive Visit Claim Denials (from HFS)

12/03/14

Informational Notice

To: Enrolled Physicians, Advanced Practice Nurses, Federally Qualified Health Centers, Rural Health Clinics, Encounter Rate Clinics and Local Health Departments

Re: Preventive Visit Claim Denials

The department’s coding system regarding preventive visits was previously changed in response to audit findings and limits on preventive visits were set as follows:

• For children birth through 2 years, the number of preventive visits allowed followed the periodicity schedule found in Topic HK-203.11 of the Healthy Kids Handbook.
• For individuals age 3 and older, including adults, one preventive visit per year was allowed.

These changes inadvertently caused some claims received on or after November 1, 2012 through September 15, 2014, to be denied. All preventive services within the CPT range of 99381-99397 that were billed within the maximum time limit of another preventive visit were denied. The error code generated was X11- Procedure Conflicts with Program Limits.

The department recognizes that preventive visits may be required in excess of the recommended limits and has modified the system limits. Providers must re-bill the department for preventive visits that rejected X11 with dates of service November 1, 2012 through September 15, 2014.

A time override has been systematically authorized for claims resubmitted electronically, provided they match the claims that previously rejected X11. Claims that are rebilled on the HFS 2360, Health Insurance Claim Form, will require manual overrides. Instructions for the paper override process are explained in detail on the department’s Non-Institutional Provider Resource webpage. All claims, electronic and paper, must be submitted and received by the department between 11/10/2014 and 05/14/2015.

Questions regarding this notice should be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs