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Information Articles: Insurance

BCBSIL Denial of Claims with Modifiers Update

Wednesday, March 28, 2018   (8 Comments)
Posted by: ICS Staff
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BCBSIL Denial of Claims with Modifiers Update 


The ICS now has heard from numerous members about the significant financial and administrative impact to their practices, resulting from a BCBSIL claims processing protocol that began in November 2017.  When applied, this claim edit, described by BCBSIL as “code-auditing enhancement” via “clinically validating modifiers,” automatically denies some providers’ claims on codes that require the modifiers 25 or 59 (including XE, XS, XP, XU).  The EOBs state the reason for the denial as: “The procedure code is inconsistent with the modifier used or a required modifier is missing…,” even though the modifiers are both present and consistent with CPT® and other guidelines followed by BCBSIL. The denial occurs prior to, and without any request for, medical records.  Based on the volume of calls to the ICS, it appears that this “code-auditing enhancement” via “clinically validating modifiers” now is impacting a significant number of chiropractic physicians in Illinois who are participating providers with BCBSIL.


The ICS shares members’ concern that this new process has created an unjustified barrier to care for BCBSIL patients.  We have worked continuously on this matter since early December, and it is important to the ICS that members be made fully aware of all of our activities and BSBSIL’s response.  This problem is our number one priority to which we are applying most of our resources at this time.


As explained in greater detail below, our efforts have included discussions with BCBSIL liaisons, other state associations, other provider groups, national associations, our legal team, and a face-to-face meeting with a number of BCBSIL executives at BCBSIL headquarters.  At the meeting with BCBSIL, we expressed our strong disagreement with the method that BCBSIL is utilizing to deny these claims.  We asked BCBSIL to reveal the criteria used to determine the claims to which the modifier edit is applied, and we took issue with BCBSIL’s reasons for the claim denials shown on the EOBs.  We also contended that, except in rare cases, decisions regarding the valid use of these modifiers can only be determined by a medical documentation review.


Unfortunately, despite our efforts and despite providing BCBSIL with ample time and opportunity, the ICS has been given no indication that BCBSIL will cease its use of the claim edit.  Therefore, at this time, the ICS is continuing to advise its members to take all steps possible to contest the denials based on this claim edit, as well as to mobilize BCBSIL patients to take their own action.  Additionally, the ICS will be presenting patient education materials and physician education specifically targeted at this issue, as well as coding, billing and documentation of both therapies and evaluation and management codes.  These classes will be designed to assist our members in their ability to provide necessary, evidence-based, efficient treatment for their patients; to maximize reimbursement; and to succeed in appeals following claim denials.  At the same time, the ICS is looking into other recourse that may be available to our members and to the association as a whole, and we have not ruled out any options.


Here is background information on the BCBSIL claims processing protocol and updates on our activities, including our meeting with BCBSIL: 



In November 2017, BCBSIL instituted a claims processing protocol -- “code-auditing enhancement” via “clinically validating modifiers” -- that began denying some providers’ claims on codes that require the modifiers 25 or 59 (including XE, XS, XP, XU). After making initial contact with BCBSIL regarding the change, we were informed that the change would only impact a small number of providers; that it would impact several provider groups; and that BCBSIL was using claims processing data analysis to identify the claims to which the protocol is applied.


Based on our call volume, we believe that the change has, in fact, impacted a significant number of chiropractic providers in the BCBSIL network.  BCBSIL has not revealed any standard protocol used to identify claims to which the edit is applied, although BCBSIL has indicated that it is designed to identify medically unnecessary evaluation and management (E & M) services and manual therapy services (CPT® Code 97140) to curb the practice of some providers of performing and/or bill E & M services at every visit, as well as the practice of routinely providing 3-4 units of massage billed under 97140, when these services are not medically necessary.  Finally, BCBSIL has told us that this policy is applied not by provider type but is applied across all claims that include these modifiers.  In addition to extensive research and conversations with individual doctors around the state, we have talked about the billing practice and claim denials with several other health care provider associations whose members have also been affected, including medical doctor and physical therapist organizations; national health care associations; attorneys; Certified Professional Coders; compliance experts; and many others.


Meeting with BCBSIL

In addition to the activities listed above, the ICS met on March 7, 2018, with a team of BCBSIL representatives, including senior managers.  The ICS expressed strong disagreement with the process applied to claims with these modifiers, particularly if the purpose of the edit is to recognize medically unnecessary services.  We asked BCBSIL to describe the criteria used to identify which claims will be subjected to the edit, because we cannot see any pattern in the examples we have reviewed.  We believe fairness dictates that network doctors be made aware of the rules BCBSIL applies in these cases.


In response, BCBSIL representatives stated the following about the Claims Edit Process applicable to network providers: 

  • The claims edit will look for “clinical validation” for modifiers 25 and 59 to validate the way modifier use is supported.  This initial stage of clinical validation does not include medical records review.
  • This edit is not applied based on a provider’s history; the methodology applies to a patient’s claim history and is applied to claims, not to providers.
  • The methodology for deciding when the claim edit is to be applied to a particular claim:  a nurse claims analyst reviews the claim history for that patient.  If, in the judgment of the analyst, the patient claims history warrants use of the edit, it will be applied to that claim and the service will be denied. If the patient’s claim history shows a certain frequency of procedures for that patient, the edit will be applied and the claim denied, even if some of the procedures were performed by a physician other than the one submitting the current claim.
  • Every BCBCIL covered member-patient is treated differently, depending on claims history.
  • In response to the ICS’ question regarding specific guidelines BCBSIL uses to determine which patients’ claims are subject to the claims edit, BCBSIL repeatedly stated that to answer this question, BCBSIL must have examples of how the edit is being applied unfairly for them to review and explain to the ICS how the analyst decides when a claim warrants the edit.  (The ICS provided examples to BCBSIL both before and after the meeting.)  The ICS asked whether the guidelines applied by BCBSIL were based on a specific CMS alert; BCBSIL answered, “No.”
  • BCBSIL asserted that 3% of their total claims with modifiers 25 and/or 59 are being denied.  This statistic is based on the total number of claims submitted with modifiers and is not provider-specific.  BCBSIL said that they therefore cannot extract data to identify whether the claim edit is having a disproportionate effect on claims submitted by chiropractic physicians.
  • The provider who receives a denial under this claim edit may submit a Claim Inquiry/Request for Reconsideration or appeal, or both, and submit medical records for review.
  • A claims inquiry is not an appeal; it is a provider inquiry, and if the provider wants a claims inquiry, he or she should ask for a reconsideration.  The provider will still need to send in records; however, this is an additional process that does not waive the provider’s right to also appeal.  An inquiry is triaged to a different area of BCBSIL with different staff.  Appeals go to a separate unit.  Correct terminology will result in correct routing and faster response.

The ICS has questioned EOB denial language that informs the patient the claim is denied because the provider used incorrect coding.  BCBSIL acknowledged that the language could be questioned, so they will be making changes.  However, they are in the process of “operationalizing” and stated they could not provide it to the ICS at the time of the meeting or when we asked again after the meeting. We have recently seen slightly different language on one EOB, but BCBSIL has not discussed or shared new language with us, so we still do not know what new standard explanation will be provided on patient EOBs as the reason for these denials.


Current Recommendation and Upcoming Information

The ICS takes issue with the method BCBSIL is using to deny these claims; with the lack of information about how they decide which claims are subject to the claim edit; with the explanation provided to patients on the EOB; and with the appropriateness of evaluating the medical necessity of a provider’s examination based on examinations by previous providers. Therefore, we continue to recommend that doctors file a claim inquiry and/or appeal for each denial in which they believe BCBSIL has improperly applied the claim edit.  Detailed instructions for filing a claim inquiry may be found on the ICS website at:  In addition, providers still have the option of filing an appeal (in addition to a claim inquiry) within 180 days of the denial. The actual difference between a claims inquiry and an appeal remains vague, other than the claim is routed to a different (more appropriately staffed) department and does not impact the ability to take all appeal steps on a claim.


We understand that the routine filing of these inquiries and appeals places a strain on our already administratively-burdened members.   However, we continue to believe it is the best protection for our members, based on what we know today.


Equally importantly, the ICS believes that patients’ involvement in their own health care and coverage has a significant impact on quality of care and fairness of reimbursement.  In the coming weeks, the ICS will provide materials for our members to give patients to educate them about how the BCBSIL claim modifier protocol is being applied and impacting their reimbursement, and, in turn, their ability to receive care.  Patients may then use this information to urge others involved in health care insurance decisions (e.g., employers, other plan sponsors, or agents) to advocate on patients’ behalf so that they receive agreed-upon reimbursement for medically necessary, evidence-based required examinations and care.


Additionally, the ICS is continuing to review the most recent BCBSIL provider agreement and provider manual to prepare information about billing patients for denied services.  We will publish that information in the near future.


Although we would have preferred an agreed resolution with BCBSIL, we must move forward based on the circumstances.  As soon as we have additional information on this problem, we will notify chiropractic physicians through a special email release or the Illinois Practice Edge. Please encourage your colleagues to subscribe to our email notices here:


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Steven M. Santolin DC says...
Posted Wednesday, May 30, 2018
Marc, Are these ERISA appeals that are being filed when no response or upheld denial response to claim reviews?
Steven M. Santolin DC says...
Posted Monday, May 21, 2018
Marc, Are these ERISA appeals that are being filed when no response or upheld denial response to claim reviews?
Marc Abla CAE says...
Posted Monday, May 14, 2018
Based on the information that our doctors are sharing with the ICS, we are seeing significant delays in both the claims inquiry and appeal process. Those that have received responses and let the ICS know, the results vary. It appears that many are being denied (upheld) and a few reversed.
Steven M. Santolin DC says...
Posted Saturday, May 12, 2018
Just spoke to an office yesterday that first filed claim reviews in early Febuary and has not received a response to any of them. What is the ICS experience on BC response to the modifier claims reviews?
Robert B. Rice DC says...
Posted Saturday, April 7, 2018
I work for Dr. Rice as well as several other chiropractic physicians in Illinois. Based on what I am seeing with all my offices, I have serious doubts about this methodology BCBS states they are using to apply this edit. It would seem that EVERY claim (exception BCBS Federal), for every patient and every doctor, is automatically denied for exams and therapies requiring the -25 or -59 modifier. Additionally, I too have mailed in the notes according to the BCBSIL process and those visits came back denial upheld, same as Dr. Godo below. Why? The exam notes were previously reviewed by a well known and respected compliance officer in this industry , and he approved them. So I will conclude that the "3% of claims affected" are belong to Chiros and PT's and that BCBSIL has every intention of making the process so difficult and costly that ultimately they never pay a dime of that 3%. See you Saturday.
Jason P. Godo DC says...
Posted Wednesday, April 4, 2018
I have found since November 2017 , all of my BCBS claims with modifier -25 on office visits have been denied EXCEPT the federal BCBS policies. Since February of 2018, I have sent in all of my 2017 claims on modifier -25 that were denied using the "inquiry" recommendation of the ICS's instructions on how to file, not an appeal. We have checked every week so far on the status of all the 2017 claims, and none of them have had a change in status or other information yet. We have been waiting for a response to see if they needed more information before submitting all the claim denials beginning 2018 as an "inquiry". I will be attending the Heartland Symposium this weekend to see what Mario and the ICS suggests. Note: there is a 180 day window for file and appeal. April will begin the 180 day mark to file the appeals. So, I will need to begin filing appeals for the November 2017 claim denials on the -25 modifiers on top of the current "inquiries" already completed for 2017.
Marc Abla CAE says...
Posted Monday, April 2, 2018
Dr. Labelle - We are not aware of the impact on out-of-network providers. However, most limitations come as a result of the provider agreement.
Patrick D. Labelle DC CCSP FMS SFMA CKTP says...
Posted Thursday, March 29, 2018
Thank you for all the hard work. We will continue working these claims in my office through the claims inquiry tool. Can you tell me if out-of-network providers are also being subjected to this edit? If this is not resolved by September I may have to get out of network by the end of the year.

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