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Hi,

 

My physician ordered an IgG sensitivity test CPT 86001, which I did with an in-network provider (Quest Diagnostics). The insurance (Aetna) denied the claim saying "Your plan pays for charges we find to be reasonable and appropriate based on professional standards of safety and effectiveness for diagnosis, care or treatment. This service does not meet that requirement". The initial diagnosis code was L30.1. After the first claim was denied, the physician and the lab submitted another claim with updated diagnosis codes K52.29 and Z91.02. Again, the claim was denied for the same reason. Aetna says that the CPT 86001 test cannot be used with these diagnosis codes. As a result, I am responsible for the full balance. Is there a way to know what diagnosis code would be allowed with this test? Since the lab is in-network, and the test is not excluded by Aetna (i.e. there is a pre-negotiated in-network member lower rate between Quest and Aetna for this test), is the lab allowed to balance bill me instead of billing me at the lower contract rate with Aetna? Otherwise, the lab has a financial incentive to go after my direct payment rather than try to help me get this paid by the insurance. Wouldn't that be illegal?

 

Thanks.

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Contact Quest and your Dr and have THEM get the correct codes.

 

IF they can not get Aetna to accept their submittal, contact Aetna and get an EOMB statement from them that will show how much they WOULD have paid IF it had been allowed.

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Thank you for the reply. I know how much they would have paid if it had been allowed from the claim details, but that is not what I asked. Part of my problem is that Quest demands full balance payment and would not accept the in-network amount as a full payment. Their argument is that since the claim was not allowed by Aetna, I am responsible for the full balance amount, and the fact that they are in-network with Aetna does not matter. Do you know if this is illegal? The logic suggests that the payment should be limited to the in-network amount, otherwise Quest has financial incentive to have insurance claim denied and go after larger full payment.

 

I have contacted Quest and the doctor. They already submitted diagnosis codes twice. The claim was denied both times.

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Posted (edited)

So, I'm going to assume that you received an EOB from Aetna which explained that the coverage for the test was denied.  Typically, that EOB would display the amount that you were on the hook for, as a  result.  Is this consistent with what you received from Aetna?

 

Also, is the provider designated as a "preferred" or "in network" provider under your insurance coverage?

Edited by hdporter
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