State Medicaid Agency Claims Denial Question Reference Sheet This document provides targeted questions to ask State Medicaid Agencies regarding claim denial. It is intended for use by third party billers and accounts receivable staff members and suggests questions to ask when following up on claim denials. 1. Are Preventive Medicine Visits (Well Adult/Adolescent/Child) covered (reimbursable) when performed with other services such as HIV screening tests, immunizations, etc.? 2. Are Preventive Medicine Counseling Visits a covered (reimbursable) service? If so, are there specific codes that should be reported for these services? 3. Is routine HIV screening a covered (reimbursable) service or only when the service is deemed medically necessary? Are there specific codes that should be reported for these services? 4. Which provider types can perform and bill for HIV screening tests? 5. Is there a minimum age/maximum age limit on HIV screening tests? If so, what is the minimum age/maximum age? 6. Are there any utilization limits, utilization caps or frequency limits on HIV screening tests? If so, please advise what are they? 7. Which HIV screening tests are considered CLIA waved tests? Are modifiers required when reporting CLIA waved tests? If so, which modifiers should be appended? 8. Are there any utilization limits, utilization caps or frequency limits on HIV antiretroviral therapy? If so, please advise what are they? 9. Is there a billing manual or a standard set of billing instructions that can be referred to for further billing/coding questions? Are there any upcoming webinars or conferences on HIV billing and coding? 10. Does the state Medicaid agency cover copay/deductibles for dual eligible patients (Medicare/Medicaid)? Are Medicaid (only) patients responsible for any copays 11. Should the services be submitted on a CMS 1500 claim form, UB92 or is there another claim form type for submitting these services? 12. Are HIV primary care providers reimbursed an Enhanced rate for rendering health care to patients with HIV/AIDS? If so, what is the provider enrollment process? 13. Are there any specific diagnoses guidelines that must be adhered to when billing for‌‌preventive medicine visits (well visits), preventive medicine visit counseling care only and HIV screening? If so, what are they?
14. In 2014, when the nation converts to the ICD-10 system, will the state Medicaid agency provide any coding support and guidance? PROPRIETARY INFORMATION PREPARED BY STACEY L. MURPHY FOR USE By HealthHIV