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Denial Incorrect: 99070 Denied for Dispensed Pharmaceuticals
When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.
To store language for Request for Second Review reasons, use DaisyBill’s Second Review Reasons. When the EOR you receive from the claims administrator incorrectly states that the billed pharmaceuticals are not reimbursable or are “bundled” into other paid services, we recommend language similar to the Second Review reason in this article.
Official Medical Fee Schedule
Pharmaceutical Fee Schedule
EOR Denial Reason
The amount adjusted is due to bundling or unbundling of services.
Second Review Reason (SBR-1 Form)
Reason for Requesting Second Bill Review
The NDC number billed for this date of service is valid and payable. Per OMFS §9789.40(a) Pharmacy Fee Schedule, the maximum reasonable fee for pharmaceuticals and pharmacy services is 100% of the reimbursement prescribed in the relevant Medi-Cal payment system, including the Medi-Cal Professional fee ($7.25) for dispensing.
Per § 9789.13.3 reimbursement for Physician Dispensed Drugs is calculated using the Pharmaceutical Fee Schedule §9789.40.
§ 9789.40 Pharmacy Fee Schedule does not include billing instructions and does not utilize CMS Status Codes to determine reimbursement amounts, therefore, CPT code 99070 is not "bundled" into other paid services.
We elect to use 99070 in lieu of S5000 and S0001 which are ‘By Report’ HCPCS and not payable per §9789.12.4 (b)(2) which states: “CPT codes that: 1) appear in the CMS’ National Physician Fee Schedule Relative Value File, and 2) do not have an RVU assigned for the service, and 3) that are payable under a fee schedule contained in section 9789.30 - 9789.70, are not payable under the physician fee schedule on a “By Report” basis .”
- California Code of Regulations, Title 8, §9789.12.4 (b)(2)
- California Code of Regulations, Title 8, § 9789.13.3
- California Code of Regulations, Title 8, § 9789.40
Other Second Review Topics