As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 99214 |
Office or other outpatient visit, established patient, moderate complexity
E11.9 · Type 2 diabetes mellitus without complications
|
$133.60 | $133.60 | — | Correct |
Determination
Reviewed with no variance. Every line was paid at the allowable on file.
How it was coded
Remedy: None — the claim was billed and priced as the record supports
Reviewed for level, severity and unit count. Nothing billed above what the record carries.
Prior authorization
No prior authorization requirement for this service on this plan.
Policy applied
Knowledge CenterCoverage on the date of service, and the grace-period rule that applies to it
4. Variations by state and line of business 4.1 Marketplace qualified health plans A member receiving an advance premium tax credit has a three-month grace period for non-payment of premium. Claims for services in the first month are paid. Claims in months two and three may be pended and, if the premium is not paid by…
e termination after the date of service creates no exposure. 4.3 Medicare Advantage A retroactive disenrolment processed by CMS makes the plan not liable for the period concerned. Reconciliation follows the monthly membership report.
Level selection for the visit billed
v4.2 was extracted from CPP-014_em-level-selection_v4.2.md. Passages are quoted only on the policy the finding rests on.