Re: CPT code / Procedure Code for ABA for BCBS

[Guest guest]

Serena,

Have you tried calling BCBS to ask them which codes they reimburse for? Or maybe

your BCBA could call and confirm benefits once the insurance kicks in? We're

still waiting for our BCBA to even get on the insurance as a preferred

provider...

Bonnie

>

> Hey there. Our ABA benefits are about to kick in with TRS Active Care through

BCBS, and I need a procedure code so that I can figure out whether our BCBS's

rate is going to be the same as BCBS' allowable amount. Anyone have one they

care to share?

>

> Thanks!

> Serena

>

[Guest guest]

BCBS gave me the runaround, and acted like I was trying to cheat them

somehow by asking what their allowable costs were for ABA. I'm going

to ask our BCBA today, but I figured I could get a variety of codes

from this group, just in case we needed to try a few different ones. I

really want to avoid waiting until the last second to ask questions.

Since our ABA benefits are unlimited, if I took full advantage of that

and tried to get a 20+ hour per week program going, only to find out

that the allowable charge was half of what the customary charge that

the BCBA was using, I'd be in huge trouble when it came time to be

reimbursed. If my BCBA's customary rates are the same or lower than

the allowable charges, I'm golden (after I come out of pocket a few

thousand for deductible and out of pocket maximums, that is). I just

don't want to wait any longer to really build a good ABA program, and

I also don't want to put my family in financial jeopardy by paying the

BCBA a couple grand and then getting reimbursed a couple of hundred,

know what I mean?

Serena

[Guest guest]

I have BC/BS as well and one of the tricks these use is that they have a maximum reimbursement for each session but they consider a session to be 15 minutes. So if your provider is charging by the hour you will run over your limit but if you can get them to do the billing in 15 minute increments it is more likely to get paid (although I still have my insurance broker call after every EOB to explain that to BC/BS how their own system is supposed to work)

Subject: Re: CPT code / Procedure Code for ABA for BCBSTo: Texas-Autism-Advocacy Date: Wednesday, August 10, 2011, 11:30 AM

BCBS gave me the runaround, and acted like I was trying to cheat them somehow by asking what their allowable costs were for ABA. I'm going to ask our BCBA today, but I figured I could get a variety of codes from this group, just in case we needed to try a few different ones. I really want to avoid waiting until the last second to ask questions. Since our ABA benefits are unlimited, if I took full advantage of that and tried to get a 20+ hour per week program going, only to find out that the allowable charge was half of what the customary charge that the BCBA was using, I'd be in huge trouble when it came time to be reimbursed. If my BCBA's customary rates are the same or lower than the allowable charges, I'm golden (after I come out of pocket a few thousand for deductible and out of pocket maximums, that is). I just don't want to wait any longer to really build a good ABA program, and I also don't

want to put my family in financial jeopardy by paying the BCBA a couple grand and then getting reimbursed a couple of hundred, know what I mean?Serena

[Guest guest]

Serena,

We went through this. Our provider billed in 15 minute increments. One unit = 15

minutes. CPT code was 96152. Description was Health and Behavior Intervention.

Cost was $16.25 per unit (15 minutes) They eventually covered 70% after we met

the deductible. However about every other week they'd flat out deny it. I'd just

email them, ask them to review it, and give them a claim # to refer to where

they'd processed it correctly, and they'd do it right.

They did require the provider (who was out of network) to call them and get an

authorization # first though for 6 months at a time.

Before this we were using CPT code H2019. Description was ABA Therapy. With

that, they only paid 70% of a tiny little " allowable " amount. Ridiculous! They

were only " allowing " around $8 per 15 minute unit and just paying 70% of it.

We are no longer with BCBS. So we are having to start this all over again with

United.

Best of luck to you.

>

> Hey there. Our ABA benefits are about to kick in with TRS Active Care through

BCBS, and I need a procedure code so that I can figure out whether our BCBS's

rate is going to be the same as BCBS' allowable amount. Anyone have one they

care to share?

>

> Thanks!

> Serena

>

[Guest guest]

I got the runaround with them when I called a few months back, too. I was

looking for reimbursement rates, not codes, so I thought maybe they would be

more forthcoming with the codes, since they don't change like the reimbursement

rates. Insurance co's are very secretive about their allowables, I know. I used

to work for a non-profit mental health agency. Generally speaking, providers

often do the same thing. They have " cash " rates and they don't want the

insurance co's to know what these rates are or else the insurance co's will

demand those rates and then really try to screw over the provider and the little

man - you and me.

96152 was the code we were given by the billing person for our BCBA. They bill

somewhat differently, though, submitting for the entire hour at a time. I've

seen a number of other codes around the net, as well, like 90806; 90808; 97532;

97533. There are more, I just can't remember them all and I don't know for sure

how well they work. Our BCBA's biller says he's had the best luck with 96152,

but of course, he hasn't had much experience billing this to BCBS.

I wish some TRS employees (if any are present) with experience using the

insurance for ABA would jump in and comment on what has worked for them.

I know the TACA website has some information on codes that work, but I can't get

their website to open right now. www.tacanow.org

HTH's!

Bonnie

>

> BCBS gave me the runaround, and acted like I was trying to cheat them

> somehow by asking what their allowable costs were for ABA. I'm going

> to ask our BCBA today, but I figured I could get a variety of codes

> from this group, just in case we needed to try a few different ones. I

> really want to avoid waiting until the last second to ask questions.

> Since our ABA benefits are unlimited, if I took full advantage of that

> and tried to get a 20+ hour per week program going, only to find out

> that the allowable charge was half of what the customary charge that

> the BCBA was using, I'd be in huge trouble when it came time to be

> reimbursed. If my BCBA's customary rates are the same or lower than

> the allowable charges, I'm golden (after I come out of pocket a few

> thousand for deductible and out of pocket maximums, that is). I just

> don't want to wait any longer to really build a good ABA program, and

> I also don't want to put my family in financial jeopardy by paying the

> BCBA a couple grand and then getting reimbursed a couple of hundred,

> know what I mean?

>

> Serena

>