Mandated states and egg retrieval
I found a few answers within your archives in third-party category that address how to submit a claim for reimbursement for the day of egg retrieval performed on the donor, however the answers do not seem to align with the benefits being afforded for this process in states that are mandated. My questions are: What name should you use to submit for reimbursement for the actual egg donor when there is benefit for the donor egg retrieval. Should we utilize just the recipients full legal name even though they are not having the egg retrieval, or should we code the name by Donor# so the plan understands the service is not being performed on their member?
Background: In NJ, you are allotted four egg retrievals, and the egg retrieval can be performed on an ovum donor. They do not exclude the retrieval from this benefit; therefore, the recipient is entitled to some form of claim process. When prior approvals are issued, claim processing is not problematic as we can lean on those prior approvals to then submit a claim under the recipients last name, and a donor number for the first name, which offers clarity that the recipient is not having the retrieval and a donor is being utilized. We are struggling to get reimbursed when these same benefits exist, but the plan design does not require prior approval. We use the same method for submitting, with recipient last name, donor number as first name, and the claims are getting denied. What is the recommended compliant way to submit to a plan when a donor is being utilized and the recipient had full donor services benefit?
Background: In NJ, you are allotted four egg retrievals, and the egg retrieval can be performed on an ovum donor. They do not exclude the retrieval from this benefit; therefore, the recipient is entitled to some form of claim process. When prior approvals are issued, claim processing is not problematic as we can lean on those prior approvals to then submit a claim under the recipients last name, and a donor number for the first name, which offers clarity that the recipient is not having the retrieval and a donor is being utilized. We are struggling to get reimbursed when these same benefits exist, but the plan design does not require prior approval. We use the same method for submitting, with recipient last name, donor number as first name, and the claims are getting denied. What is the recommended compliant way to submit to a plan when a donor is being utilized and the recipient had full donor services benefit?
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