Every year we see at least one carrier denying codes that were previously paid. So far this year we’ve had two carriers that all of a sudden started denying codes that were previously covered and paid.
The first was the VA CCN program managed by Triwest. In May providers stopped being paid for E/M codes that were AUTHORIZED! (Yes, you read that correctly.) On social media, letters of appeal were circulated encouraging Triwest to PAY for E/M codes because acupuncturists “deserve” to be paid, etc. Many calls were also made. All of this work was useless and providers continued to receive denials. They were useless because they didn’t give the information necessary for the carrier to realize it was indeed their error.
When a letter was sent explaining the backstory and WHY it HAD to be a database error, Triwest admitted the error, fixed it going forward and reimbursed payments denied.
This same situation is happening starting in August with Regence BCBS in OR/WA. Previous modalities that were previously paid started being denied, across the board, by all providers. When providers called Regence they were told – they needed to use a correct modifier. Since this carrier didn’t require -GP (as some carriers do), that was then tried again without success. People then started trying other modifiers, as the reps were giving out Regence Modifier policy.
It wasn’t a modifier issue. It was a database issue, just like with Triwest. I have now created an appeal, with background documentation and I am confident that the result will also be the same – they will fix the issue, and reimburse unpaid claims. WHY do I know this?
How to Spot a “Glitch Denial” vs. a Real Denial
When you get denials for codes that were previously paid, here’s what you must keep in mind:
- Carriers can’t change contracts mid-year.
If you’re in-network, the carrier can’t suddenly remove covered benefits or change payment terms without notice. - Don’t rely on what reps say over the phone.
Frontline reps have limited information and often can’t imagine that the carrier itself could be wrong. - Check the denial reason.
When you see language like “not a covered benefit” or “incidental to the primary procedure,” that usually means something changed in the carrier’s processing rules (their database). Because they can’t legally make that change without notice, you can safely assume it’s a system error—and it’s fixable.
When a Carrier denies an E/M Code
E/M denials are a little different—but they’re not always true denials either. Unless your contract specifically excludes E/M services, a denial is usually the carrier’s way of saying: “Prove it.”
That means you need to submit notes that clearly document medical necessity and meet coding standards. Unfortunately, many providers either don’t send notes or send documentation that doesn’t meet requirements, which is why those appeals fail. (See my full article on E/M denials for guidance.)
👉 The bottom line: Don’t assume every denial is valid. Learn to distinguish a true contractual denial from a processing glitch—and respond with the right type of appeal.