| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | |
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1 | Payor | Last Updated | Issue Title | Description of Issue | Status | Action | Current Status | Resolution | Impacted Practices | Date Issue Discovered | Date Resolved | |||||||||||||||
2 | Peach State Health Plans | 7/2/2025 | Ordering, Prescribing, Referring (OPR) Rejections | Peach State claims are rejecting with an Ordering, Prescribing, Referring (OPR) reason code. | Resolved | This is a global processing issue. Practice provided example information to submit to Peach State for review. | Resolved | Peach State resolved the rejection issue as of 6/27/2025. They are actively working to reprocess the affected claims. Providers also have the option to resubmit any rejected claims, if preferred. Reprocessing claims may take up to 2 weeks. | 199 | 6/13/2025 | 7/2/2025 | |||||||||||||||
3 | Aetna | 6/26/2025 | Split Claims Denials Impacting Immunization Admin Codes | Aetna is splitting claims which is causing denials. The original claim has a 25 modifier on the office visit. When the claim splits, the modifier is dropped causing denials. | Open Issue | Claims examples were sent to Aetna to identify the processing error. An initial response came from Aetna’s Medical Policy Coding Dept. They stated the correct coding editing in place is allowing the higher priced RVU code and denying the incidental code based on the National Correct Coding Initiative (CCI) for Medicare Services. CCI has identified comprehensive procedure codes and their associated component codes. When Column I/ Column II code pairs are billed for the same date of service, then the procedure with the highest RVU price is reimbursed. | Practice disagrees with the response from the rationale. KHF made further inquiries with Aetna. | Aetna's Medical Policy Dept confirmed there is an error causing claims to split bill. As they research a solution to correct their system, Aetna is reprocessing claims that meet the following criteria: "CPT 90460 and 90461 can be paid in addition to the routine E&M when the routine E&M 99391-99394 is billed with modifier 25. If the 99391-99394 it is not billed with modifier 25, the incidental editing still applies and no rework will be done." Aetna is submitting a project for the (7) KHF practices that have reported denials. The claims project can take up to 60 days. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 170, 350, 675, 952, 259, 794, 809 | 2/11/2025 | ||||||||||||||||
4 | Anthem (TCCN) | 6/20/2025 | Northside Hospital Underpayments | Anthem's pricing of Northside Hospital's direct contract is underpaying. It appears to be pulled from outdated fee schedules. | Open Issue | Northside Health Network Informed TCCN that they presented EOB examples to Anthem. Anthem confirmed a issue with their claims processing systems. The issue was corrected on 5/22/2025. Claims processed as of 5/22/2025 should pay at the correct Anthem fee schedule. | TCCN pending confirmation claim project closed. | Northside Health Network confirmed 100 claims underpaid early in 2025. Claim system corrections were made on 5/21/2025. A claims project was initiated and will take approximately 30 days to complete. | 496, 986, 628 | 5/14/2025 | ||||||||||||||||
5 | Cigna | 6/18/2025 | Tier 1 Client Specific Network | Cigna didn't not include all KHF practices in their Tier 1/Client Specific Network. This caused claims to process with the incorrect member responsibility. Piedmont is one of the employer groups using the Client Specific Network. | Open Issue | Cigna added KHF practices to their Tier 1/ Client Specific Network around 2/27/2024. On 2/27/2024, Cigna advised they were reprocessing claims 1/1/2024 forward, except for specifically identified providers who will have 2023 claims reprocessed. Reprocessing was to take 45-60 business days (Approx due date late May 2024). On 6/24/2024, received confirmation that some, providers were still not added to the Client Specific Network. | KHF escalated issue to supervisor of Cigna rep due to no response or resolution. | Two providers are confirmed fall outs from Piedmont CSN. Manager overseeing the addition of those providers. Some impacted claims are already adjusted. Remaining claims in process. Pending claim report. | 628, 986 | 11/21/2023 | ||||||||||||||||
6 | Anthem (TCCN) | 6/16/2025 | The Home Depot Employer Plan | Practices are receiving out of network denials for The Home Depot employer plan that utilizes the Blue Open Access network. TCCN is contracted for this network and providers should be in network. | Resolved | Anthem customer service confirmed The Home Depot employer plan uses Anthem's standard Blue Open Access network. They do not use a "narrow network." In the examples we’ve received from practices and discussed with Anthem, practices may be listed as in network, but individual providers are not. TCCN has escalated this issue to our Provider Rep for focused assistance on the provider loads. TCCN also received reports that some practices are receiving 3rd party requests to negotiate out of network claims. Practices do not need to entertain these requests at this time. | Resolved | Due to a benefits configuration error at Anthem, some TCCN practices/providers were incorrectly listed as out-of-network for The Home Depot employee health plan beginning 1/1/2025. Anthem Customer Service informed patients and practices that practices were out of network as The Home Depot had moved their employees to a narrow network product effective 1/1/2025. This resulted in claims processing at out-of-network rate or denials. TCCN Anthem-participating practices are contracted as in network providers. Anthem confirmed issue was corrected on 2/19/2025. The claims project completed on 6/13/2025. No action is required by practices. Contact your TCCN PR rep after 6/13/2025 for fallout claims. | 280, 794, 180, 628, 255, 256, 986, 118, 578 | 1/31/2025 | 6/13/2025 | |||||||||||||||
7 | Amerigroup (TCCN) | 6/12/2025 | Amerigroup Rate Loading Delays | The Amerigroup contract, effective 1/1/2025, is not loaded yet. | Open Issue | TCCN leadership has escalated to Amerigroups executives to get status and timeline on when the rates and PMPM will be loaded. Claims to be adjusted after contract loaded. | TCCN pending confirmation claim project closed. | As of 5/22/2025, provider load completed. As of 6/12/2025, claims project in process. | All Amerigroup contracted practices. | 1/1/2025 | ||||||||||||||||
8 | Anthem (TCCN) | 5/16/2025 | Effective Date Change Error | Anthem incorrectly processed TCCN’s April roster. 72 providers (51 practices) impacted. Anthem changed their effective dates to 5/20/2023. | Resolved | Correction to effective date complete. Anthem submitted the claims projects under impacted practices for adjustment. | Resolved | Partial Status: Commerical claim adjustments made 6/14/2024. Confirm FEBHP claims and remaining claims were paid on or before 5/16/2025. | 705, 350, 219, 809, 141, 170, 180, 193, 960, 744, 628, 118, 986, 578, 794, 199 | 7/24/2023 | 5/16/2025 | |||||||||||||||
9 | CareSource (TCCN) | 4/23/2025 | NP and PA Recoupments | Practices are receiving recoupments for NP and PA claims. | Resolved | TCCN’s CareSource contract was effective 1/1/2025. CareSource paid NP and PA claims at the physician rate instead of the non-physician rate. CareSource sent recoupment letters to collect the overpayment between the non-physician rate and the physician rate. | Resolved | NP and PA overpayment recoupments are accurate. To review the contract terms and confirm the fee schedule, please login to Luviel. (https://fsapp.luvielhealth.com/tccn/fs/index.asp). Contract terms are found under the “View Fee Schedule Menu” at the top. | CareSource contracted practices with NP's & PA's. | 4/14/2025 | 4/23/2025 | |||||||||||||||
10 | Amerigroup (Pre-TCCN & TCCN) | 4/23/2025 | CPT 99213 & 99214 Claim Adjustments | Amerigroup experienced severe delays updating 7/1/2024 Medicaid fee schedule with new rates for CPT’s 99213 and 99214. | Resolved | In early April, claims for DOS 7/1/2024 - current were adjusted by Amerigroup to pay the DCH fee schedule rate increase. Practices could receive numerous remits for adjustments under their previous contracts (for 7/1/2024 - 12/31/2024). | Resolved | TCCN's Amerigroup contract was effective 1/1/2025. TCCN practices will see a zero payment because claims after 1/1/2025 already paid at the correct Medicaid rate. Since TCCN’s new contract is not loaded, 2025 claims continue to be underpaid. (See issue entitled Amerigroup Rate Loading Delays.) | All Amerigroup contracted practices. | 4/14/2025 | 4/23/2025 | |||||||||||||||
11 | CareSource (TCCN) | 4/23/2025 | CareSource Rates Loaded and Claims Project Impact | CareSource new rates from 1/1/2025 amendment were not loaded in a timely fashion. | Resolved | CareSource confirmed the TCCN’s January 1, 2025 contractual rates were loaded on 3/3/2025. CareSource is initiating a claims project for date of service 1/1/2025 to 3/3/2025 to pay at the new fee schedule. There is no action required by the practices. The Per Member Per Month (PMPM) change, effective 1/1/2025, is loaded as well. Practices will see a decrease in their upcoming monthly PMPM reports. Please note, TCCN's analysis confirms that the decrease in PMPM is fully offset by the increase in the fee-for-service rate. To review the new contract terms and fee schedule, please login to Luviel. (https://fsapp.luvielhealth.com/tccn/fs/index.asp). Contract terms are found under the “View Fee Schedule Menu” at the top. | Resolved | Claims project completed on 3/24/2025. If a practice identifies an outstanding claim, please notify your TCCN rep. | All CareSource contracted practices. | 2/27/2025 | 3/24/2025 | |||||||||||||||
12 | Anthem (TCCN) | 3/28/2025 | University System of Georgia Employer Plan | Practices are receiving out of network denials on University System of Georgia (USG) Employer Plan patients. | Resolved | TCCN confirmed all TCCN providers are in network with USG. | Resolved | USG has multiple plan types with differing PCP access requirements. Open Access plans, a PCP is not required. The Gatekeeper members, the PCP provider MUST be at the same location and tax ID. The BOR (Group Number Prefix) has a Gatekeeper plan. These claims will process out of network if the members PCP is not matching PCP the PCP on file plus location plus TIN. | All Anthem contracted practices. | 2/15/2025 | 3/28/2025 | |||||||||||||||
13 | Aetna | 3/18/2025 | Denying CPT 90660 for COVID | Aetna is denying CPT 90660 stating "non covered because it's not proven COVID effective". | Open Issue | Aetna confirmed there is a company-wide denial issue for CPT 90660. As of 3/18/2025, On 3/18/25 claim system is still denying codes. Aetna escalated internally to determine why their fix did not correct the problem. A claims project is in process and could take 60-90 days to complete. | KHF pending confirmation claim project closed. | If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 259 | 11/20/2024 | ||||||||||||||||
14 | Peach State Health Plans | 1/7/2025 | CPT 90460 Denials | Peach State is denying CPT 90460, vaccine admin code, in error stating denial must follow VFC guidelines. | Resolved | KHF contacted Peach State for explanation and resolution of claim issue. | KHF pending confirmation claim project closed. | Peach State confirmed there was a manual processing error by one claims processor. Processor was re-educated. It was corrected early in the week of 10/28/2024. Approximately 5,000 claims were adjusted and payments will be made the week of 11/4/2024. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 199 | 7/22/2024 | 1/7/2025 | |||||||||||||||
15 | Anthem (TCCN) | 12/31/2024 | CPT 87635 | For the HMO/OA/HPN and HIX networks, Anthem is applying an incorrect and lower rate for CPT 87635 than what TCCN has contracted for. Anthem maintains the lower rate is correct. | Resolved | TCCN is in communication with Anthems contractor to resolve discrepancies with CPT 87635. | Resolved | Fee schedule is accurate for specific networks. | 628, 255 | 9/20/2023 | 12/31/2024 | |||||||||||||||
16 | Aetna | 11/18/2024 | Claims Processing at Incorrect Copay | Providers are loaded as a specialist instead of a PCP. This is causing copays to be processed at the wrong amount. | Open Issue | Per Aetna, impacted providers are listed as pediatrics but their role is loaded as SPEC and not PCP. Impacted providers will have their role updates. | KHF pending provider update confirmation and claim reprocessing confirmation. | If a practice is impacted, they must notify KHF to initiate a correction. If there is a claims impact, a claim template can be provided by KHF and claims submitted to Aetna for adjustment. | 952, 986 | 9/23/2024 | ||||||||||||||||
17 | Peach State Health Plans | 11/15/2024 | Flu Code Fee Schedules | Flu Codes are not updated on the DCH fee schedule and claims are denying. | Resolved | Confirmed that DCH did not update flu code fee schedules until 10/1/2024. | Resolved | Peach State had 45 days from 10/1/2024 to load fee schedule | 911 | 9/30/2024 | 11/15/2024 | |||||||||||||||
18 | CareSource (TCCN) | 10/25/2024 | CLIA Recoupments for CPT 83655 | Practices are receiving recoupment letters for CPT 83655-QW citing required modifier is missing or invalid. Practices billing with correct QW modifier. | Resolved | If a practice receives a recoupment letter for dates of service before 12/1/2024, practices can resubmit claims that are within timely filing in an attempt to receive payment. | Resolved | Prior to 12/1/2024, the QW modifier is not recognized by CareSource. Per the Public Health Lab Services, CareSource has aligned and put edits in place to deny claims for GA Medicaid members per the GAMMIS Independent Lab Services Provider Manual for CPT codes 83655 (lead), 86403 (Particle agglutination), 86689 (HTLV or HIV antibody) or 86803 (Hep-C antibody) is submitted without modifier 90 (outside lab) or 91 (repeat lab). Please refer to the link below as a point of reference which is the “Independent lab manual” on GAMMIS, page 11, section 905.3. Effective 12/1/2024, CareSource will have a new medical policy for usage of the QW modifier. https://www.caresource.com/documents/medicaid-ga-policy-reimburse-py-1462-20241201 | 259 | 10/2/2024 | ||||||||||||||||
19 | Anthem (TCCN) | 10/22/2024 | Telehealth Place of Service Denials | Anthem is denying telehealth claims for place of service mismatch when POS 10-Home and 95 modifier are billed. This is correct billing per Anthem’s Virtual Visits Policy. Practice appealed claims and received medical record requests. | Resolved | Practice appealed claims and received medical record requests. Claim examples sent to Anthem for review. | TCCN pending response from Anthem. | Claims adjusted in August/September 2024 | 578, 986, 628 | 8/15/2024 | 10/22/2024 | |||||||||||||||
20 | Peach State Health Plans | 10/8/2024 | Well Visit Billed with Sick Visit | On 2/21/2024, DCH released a message on GAMMIS on health Check reimbursement for E&M Codes and Preventative Visits. Claims are paying when CPT 99213 is billed with a well visit, but denying when CPT 99214 billed. This is contrary to DCH policy. The Peach State rep for KHF confirmed on 8/6/2024 that Peach State had not removed the claim editing in their processing system. | Resolved | Claim examples were submitted with an inquiry asking when they will remove the claim edit. Additionally the GA AAP is also investigating to assist with resolution. | KHF pending confirmation claim project closed. | Peach State removed their edit on 8/28/2024 allowing CPT 99214/99215 to be paid with well visit. A claims project will be completed to reprocess claims beginning 1/1/2024 through 8/28/2024. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 259, All contracted Peach State practices | 7/26/2024 | 10/8/2024 | |||||||||||||||
21 | Cigna | 9/10/2024 | CPT 90696 - Quadracel | Cigna denying CPT 90696, Quadracel, due to patients age. Claim examples show CPT 90696 is billed for a patient within the correct age range for the code definition. It appears when CIgna was recoding (resolved issue below), claims that contained CPT 90696 were denied when Cigna changed the E&M to a different level of service. Example: CPT 99392 changed to CPT 99395 which has an age range of 19-39. This led to denials for Quadracel, which is for patients age 4-6. | Open Issue | Claim examples submitted to Cigna citing correct age for CPT 90696. | KHF pending response from Cigna. | 578 | 8/13/2024 | |||||||||||||||||
22 | CareSource (TCCN) | 8/27/2024 | Quality Enhancer (QE) 2023 Recoupments | Claim adjustments for 2023 claims completed in March 2024 resulting in recoupments and/or additional payments, depending on practice. CareSource (TCCN contract), sent recoupment letters to a subset of TCCN practices. The recoupment letters are for the Quality Enhancer (QE) Program. CareSource changed the QE codes and modifiers in 2023 from what they were in 2022. Practices who billed 2022 QE codes and modifiers on 2023 claims are subject to the recoupment of the QE incentives for the incorrectly billed codes. Not all TCCN practices are impacted. | Resolved | None. | Resolved | CareSource (TCCN contract), sent recoupment letters to a subset of TCCN practices. The recoupment letters are for the Quality Enhancer (QE) Program. CareSource changed the QE codes and modifiers in 2023 from what they were in 2022. Practices who billed 2022 QE codes and modifiers on 2023 claims are subject to the recoupment of the QE incentives for the incorrectly billed codes. Not all TCCN practices are impacted. | Select practices only | 4/1/2024 | ||||||||||||||||
23 | Peach State Health Plans | 6/26/2024 | Duplicate Claim Lines | Claim lines are duplicating on EOBs. PSHP is not paying the duplicate lines, but the totals show they are. | Resolved | KHF sent claim and EOB examples to Peach State. | Resolved | Peach State confirmed correct claim processing. There were no duplicate lines on the claims processed. This was an issue clearinghouse. | 259 | 5/4/2024 | 6/26/2024 | |||||||||||||||
24 | United Healthcare | 6/25/2024 | CLIA QW Modifier | UHC denies selected lab codes as CLIA denials if modifier is not billed. | Resolved | UHC's CLIA policy: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-CLIA-ID-Requirements-Policy.pdf. | Resolved | UHC's CLIA policy requires the QW modifier to be added to certain lab codes. To correct modifier denials, practices should add the QW modifier where required and submit a corrected claim. | 578, 794, 986, 259 | 1/31/2024 | 6/25/2024 | |||||||||||||||
25 | United Healthcare | 6/25/2024 | CLIA Rejections/ Denials | UHC sporadically denies or front end rejects claims due to CLIA. | Resolved | UHC's CLIA policy: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-CLIA-ID-Requirements-Policy.pdf. | Resolved | Confirm your practices CLIA number is active for the applicable addresses. CLIA Website: https://qcor.cms.gov/main.jsp. Validate that the CLIA number address and the address billed on the HCFA 1500 matches. You may need to make updates to the claims form, with the clearinghouse/EMR vendor. Resubmit front end rejections or submit corrected claims once corrections are made. | 578, 794, 986, 259 | 1/31/2024 | 6/25/2024 | |||||||||||||||
26 | Cigna | 6/20/2024 | OON for Cigna+Oscar | Practice reporting Cigna+Oscar claims are processing out of network. | Open Issue | KHF sent claim examples and roster confirmation request to Cigna. Cigna completed a practice review and identified 2 providers that were not loaded as in network for Cigna+Oscar. Both provider file corrections are in process. | KHF pending data load correction and claim resolution from Cigna. | 986 | 5/1/2024 | |||||||||||||||||
27 | Anthem (TCCN) | 6/4/2024 | RSV and COVID Administration Codes | RSV and COVID administration codes, CPT’s 90480, 91304, and 96380, had their rates updated on TCCN’s fee schedules 3430 and 4257 effective 11/1/2023. The rates were loaded on 11/17/2023. | Resolved | Anthem submitted a claim sweep (29354) to reprocess claim lines for dates of service between 11/1/2023-11/17/2023. | TCCN monitoring project for resolution. | Claims Project Complete. | All Anthem contracted practices | 12/5/2023 | 7/31/2024 | |||||||||||||||
28 | CareSource (TCCN) | 5/23/2024 | Claim Adjustment Project | Claim adjustments for 2023 claims completed in March 2024 resulting in recoupments and/or additional payments, depending on practice. Attested codes paid at 100% Medicaid rate rather than TCCN contracted rate (reference info in resolved issue below). | Resolved | TCCN is pending a claim report from CareSource to validate the adjustments. However the claims project is valid and within contract parameters (rates, etc) | TCCN pending claim report and retraction letter from CareSource. | CareSource confirmed recoupments were completed in error. They will not recoup money out of future payments. Practices do not need to send in recoupment checks either. A retraction letter is being drafted by CareSource for distribution to practices. If you have questions, contact your TCCN PR rep. | All contracted CareSource practices | 4/1/2024 | 5/24/2024 | |||||||||||||||
29 | Cigna | 5/6/2024 | E&M Downcoding | Cigna downcoded E&M codes for a short time period in March 2024. Claims adjusted during this time period with earlier dates of service also experienced the downcoding. The payments appear to be processing correctly at the rate of the original code, but on the downcoded line. | Resolved | Per Cigna's rep, they confirmed a system error was identified that impacted claim denials. | KHF pending claim resolution from Cigna. | Cigna confirmed on 7/11/2024 their claims system was corrected. All affected claims will be reprocessed, though there is no ETA at this time. No action is required by practices. | 141, 259, 578, 911, 678, 675 | 3/26/2024 | 7/11/2024 | |||||||||||||||
30 | Anthem (TCCN) | 4/24/2024 | Wellstar EPO Plans | Wellstar Employee benefit plans are administered by Anthem. EPO plan must use Wellstar Health Plan providers network only (unless they live over 50 miles from a Wellstar facility). Per Wellstar, Pediatric specialties are set up to apply the EPO benefits at Tier 1 level. | Resolved | Anthem rep has contacted the Sales/Benefit team to confirm benefit set up. TCCN contacted the Wellstar PR rep requesting written documentation of EPO benefit plan, confirmation of non-Wellstar network, sample ID cards and other pertinent information. Both entitiries have numerous claim examples are are researching. | Resolved | TCCN confirmed Wellstar has an exemption for all Pediatric specialities to pay at the Tier 1 benefit level. | 255, 703, 744, 986, 628, 180 | 1/1/2024 | 5/20/2024 | |||||||||||||||
31 | Anthem (TCCN) | 4/24/2024 | Wellstar Employee Plans | Wellstar plans should pay preventative care at 100% prior to deductible. Claims are processing preventative care to patient responsibiliy in error. | Resolved | Anthem and Wellstar reviewed numerous examples and are researching. | Resolved | Anthem updated their system to 4/12/2024 to pay preventative at 100%. Claims processed before 4/12/2024 areadjusting in a claims project in May 2024. Claims processed after should pay correctly. If you have outstanding claims, please contact your TCCN PR rep. | 255, 703, 744, 986, 628, 180 | 1/1/2024 | 5/6/2024 | |||||||||||||||
32 | United Healthcare | 4/11/2024 | CPT 90670 Prevnar 13 | Beginning 2/1/2024 CPT 90670, Prevnar 13, is being applied to the patient deductible rather than paying at 100% for preventative care. | Resolved | UHC removed CPT 90670 from their Preventative Care Services list on 1/22/2024 and requires medical nurse review to have the code paid. Practices can appeal claims, but results have been mixed to date. | Resolved | KHF can provide practices a document from Pfizer showing Prevnar 13 was valid until 4/30/2024, however this is a payor/ benefit issue. The recommendation is for practices to follow UHC's dispute/appeals process. | 986, 675, 180 | 3/19/2024 | 5/31/2024 | |||||||||||||||
33 | Peach State Health Plans | 3/5/2024 | RSV Vaccine, CPT 96380 | DCH released notification: the new administration codes for Beyfortus (CPT codes 96380 and 96381) are expected to be loaded in GAMMIS in March 2024 with a January 1, 2024, effective code. Until all systems updates are completed, Health Check providers should code the Beyfortus product (CPT codes 90380 or 90381 w/EP modifier) and report the administration of Beyfortus with code 96372. | Resolved | CMO's have 45 days to load the fee schedule published by DCH. | Resolved | PSHP encourages practice to resubmit claims for payment within timely filing. | PSHP contracted practices | 3/5/2024 | 3/5/2024 | |||||||||||||||
34 | Humana | 2/29/2024 | PCV20 CPT 90677 | PCV20, CPT 90677, was denied with reason "procedure code 90677 is not typical for a patient whose age is [x months/year], the typical age range for procedure 90677 is 18 years and older." | Resolved | Practice examples sent to Humana or review. Update: Some practices notified their claims adjusted. | Resolved | Humana reprocessed underpaid claims submitted. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 255, 259, 118 | 12/6/2023 | 2/29/2024 | |||||||||||||||
35 | Aetna | 2/27/2024 | Beyfortus, CPTs 90380, 90381 | Aetna is denying Beyfortus codes, CPTs 90380 and 90381, as experimental. | Resolved | Practice examples sent to Aetna for review. Ticket to take 15-30 days for review. | Resolved | Aetna reprocessed underpaid claims submitted. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 986, 255 | 12/14/2023 | 3/11/2024 | |||||||||||||||
36 | CareSource (TCCN) | 2/15/2024 | Paying Attested at Medicaid Base Rate | CareSource was not paying claims at TCCN contracted rates following implementation. Attested codes were paid at Medicaid rate of 100% instead of TCCN contracted rate in error. 30,000 claims impacted. | Resolved | Fee schedule updated on/before 6/29/2023. CareSource initiated claims project to adjust claims from 4/20/2023-6/29/2023. | Resolved | Claim payments made March 2024. | All CareSource contracted practices | 5/9/2023 | 4/22/2024 | |||||||||||||||
37 | CareSource (TCCN) | 2/15/2024 | QE Recoupment | CareSource changed their Quality Enhancer (QE) measures and modifiers for practices in a VBR after the contract effective date. Practices used the previous years non-VBR QE codes in 2023. DOS 1/1/2023-3/31/2023 billed without dated QE will not be recouped. DOS 4/1/2023 and later may be subject to recoupments. | Resolved | In September 2023, PR reps contacted and educated practices who billed incorrect QE codes after 4/1/2023. Correct QE codes provided. A small number of practice may have QE overpayments. Recoupments may take place. | Resolved | Claim recoupment made April 2024 | 128, 150, 259, 911, 180, 810, 794, 576, 897, 874, 345, 199, 952 | 7/13/2023 | 4/22/2024 | |||||||||||||||
38 | Peach State Health Plans | 2/6/2024 | E&M Billed with Well Check | Peach State is inconsistent paying E&M's when billed with a well check. | Resolved | Claim examples sent to Peach State for clarification on their policy and claims processing. | Resolved | PSHP rep states E&M's and wellchecks billed together may require medical records to confirm both codes can be paid. It is based on the diagnosis billed on the clam. Claims cannot be adjusted without medical records. All examples provided to PSHP had records submitted by the practice and were adjusted to pay. | 911, 259 | 11/17/2023 | 2/6/2024 | |||||||||||||||
39 | United Healthcare | 1/31/2024 | PCV20 CPT 90677 | UHC has an age restriction on PCV20, CPT 90677, for children under 18. Denial reason "Not eligible due to patient's age. | Resolved | Examples submitted to United Health Care for review. Seeking timeframe that UHC will remove age restriction. | Resolved | On 1/22/2024 UHC updated CPT 90677's age range to 2 months and older. The effective date of the age range change is 6/27/2023. For denied claims, please use Availity to submit a reconsideration. Multiple claims can be submitted in one reconsideration. Fax (801-938-2100) submission is also available. | 259, 952 | 11/2/2023 | 1/31/2024 | |||||||||||||||
40 | Aetna | 1/23/2024 | PCV20 CPT 90677 | PCV20, CPT 90677, was denied after the 10/22/2023 code update with reason "Missing required provider/supplier issuance of advance patient notice of non-coverage." | Resolved | Practice examples sent to Aetna for review. Ticket to take 15-30 days for review. Two claims adjusted, two still in process. | Resolved | Aetna reprocessed all underpaid claims. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 259 | 11/7/2023 | 1/23/2024 | |||||||||||||||
41 | Aetna | 12/1/2023 | Fee Schedule Underpaid | Around 9/13/2023 Aetna claims started underpaying. This impacts numerous CPT codes on the fee schedule. | Resolved | Aetna confirmed a claim system issue took place between 9/18/2023-9/21/2023. Aetna commerical claims during this period processed according to the Aetna Market Fee Schedule instead of KHF contracted rates. This caused claim underpayments. The claims system was corrected on 9/21/2023. | Resolved | Aetna reprocessed all underpaid claims from DOS 9/18/2023-9/21/2023. If after 12/82023 a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 986, 350, 141, 578, 794, 897 | 10/2/2023 | 12/1/2023 | |||||||||||||||
42 | Aetna | 12/1/2023 | CPT 96160 | CPT 96160 is denying as "primary service wasn't performed or billed or the primary procedure has been denied." Aetna confirmed an edit for CPT 96160 was implemented on 4/30/2023 in error, causing denials. | Resolved | The edit removed on 7/7/2023. A claims project underway to capture all the denied instance of CPT 96160. All claims between 4/30/2023-7/7/2023 will be reprocessed. | Resolved | Aetna adjusted denied instances of CPT 96160 and notified of project completion on 12/1/2023. If a practice identifies an outstanding claim, please notify payorconcerns@khfirst.com. | 794, 911, 141, 628 | 6/5/2023 | 12/1/2023 | |||||||||||||||
43 | Peach State Health Plans | 10/17/2023 | Immunization Administration Code Denials | Peach State incorrectly denied immunization administration codes, such as CPT 90471, 90473, and 90460, with a denial reason of "Resubmit according to Vaccine guidelines." | Resolved | Peach State confirmed that incorrect immunization administration denials began early October 2023. The correction was put into production on 10/13/2023. | Resolved | Impacted claims will be manually reviewed by Peach State and reprocessed for payment (as appropriate) beginning the week of 10/16/2023. | 259 | 10/5/2023 | 10/17/23 | |||||||||||||||
44 | Aetna | 10/5/2023 | PCV20 CPT 90677 | PCV20, CPT 90677, was denied with reason 55 (Drug deemed experimental/investigational by payor). | Resolved | Resolved | The denial of Experimental and Investigational for 90677 ages 0-17 will terminate on 10/22/2023. The effective date is 10/22/2023. Providers can submit appeals for any DOS prior to 10/22/2023 for reconsideration AFTER 10/24/2023. | 350, 259 | 9/26/2023 | 10/5/2023 | ||||||||||||||||
45 | Cigna | 8/17/2023 | Cigna Connect Non-Par Claims | Practices no loaded for Cigna Connect causing non-par denials. | Resolved | Cigna confirmed participation in Cigna Connect. Contract load corrected and claims adjusted for 3 practices. One practice advised they may have fallout claims. KHF followed up with remaining practice three times for fallouts. | KHF marked resolved until remaining practice provides fallout claim examples. | 2 Practiced confirmed issue closed, 1 practice no response on follow ups | 141, 259, 705 | 4/19/2023 | 8/17/2023 | |||||||||||||||
46 | Aetna | 7/21/2023 | MMR/ Varicella | CPT codes for Varicella 90716 and MMR 90707 being changed during processing to the ProQuad CPT 90710. ProQuad is a combination (MMRV) vaccine. Pediatricians are providing 2 separate vaccines, but Aetna is bundling them into one. | Resolved | Aetna removed the bundling edit for CPT 90716 and 90707. Claim project initiated ~4/10/2023, allow 60 days. | Resolved | Project Complete. | 986, 350 | 3/2/2023 | 7/21/2023 | |||||||||||||||
47 | Anthem (TCCN) | 6/26/2023 | Providers Termed in Error | A company wide error terminated 27,000 providers, 9,000 of which were in Georgia. Anthem reinstated providers on 6/20/2023 with no break in coverage. Providers may/may not have claims impact. Anthem sent out non-par letters to patients and reassigned PCPs. | Resolved | Anthem reinstated providers on 6/20/2023 with no break in coverage and returned members to previously assigned PCPs. | Resolved | Anthem enterprise completed their claims adjustment. | Unknown | 5/20/2023 | 6/26/2023 | |||||||||||||||
48 | Anthem (TCCN) | 6/7/2023 | MMR/ Varicella | CPT codes for Varicella 90716 and MMR 90707 being changed during processing to the ProQuad CPT 90710. ProQuad is a combination (MMRV) vaccine. Pediatricians are providing 2 separate vaccines, but Anthem is bundling them into one. | Resolved | Anthem continues to change to CPT 90710. Both vaccines are paid under that code. Anthem claim edits are state-by-state, various plans could pay differently. BCBSGA has removed the claims edit. | Resolved | Providers have the right to appeal. | 897 | 3/2/2023 | 6/7/2023 | |||||||||||||||
49 | Cigna | 4/28/2023 | MMR/ Varicella | CPT codes for Varicella 90716 and MMR 90707 being changed during processing to the ProQuad CPT 90710. ProQuad is a combination (MMRV) vaccine. Pediatricians are providing 2 separate vaccines, but Cigna is bundling them into one. | Resolved | Bundling code denial review was completed and was determined the denial is correct per provider billing. To further dispute the denials, provider would formally appeal. In appeal, provider would include any supporting documentation. | Resolved | Providers have the right to appeal. | 986, 911 | 3/3/2023 | 4/28/2023 | |||||||||||||||
50 | Humana | MMR/ Varicella | CPT codes for Varicella 90716 and MMR 90707 being changed during processing to the ProQuad CPT 90710. ProQuad is a combination (MMRV) vaccine. Pediatricians are providing 2 separate vaccines, but Humana is bundling them into one. | Resolved | To further dispute the denials, provider would formally appeal. In appeal, provider would include any supporting documentation. | Resolved | Providers have the right to appeal. | 794, 675 | 3/2/2023 | |||||||||||||||||
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