96136 / 96137 - Sedgwick Claims Management Services: Grade F

96136 / 96137 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse 96136 and 96137 as part of a Medical-Legal evaluation. Sedgwick incorrectly denied reimbursement citing prior authorization required.

Date of Service: 09/03/2021        

MLFS Code(s)

ML201 - Comprehensive Medical-Legal Evaluation

MLPRR - Record Review

MLFS Modifier(s)

96 - Evaluation performed by a Psychiatrist or Psychologist

95 - Evaluation performed by a panel selected Qualified Medical Evaluator

Diagnostic Code(s)

96136 - Psychological or neuropsychological test administration and scoring by physician - first 30 minutes

96137 - Psychological or neuropsychological test administration and scoring by physician - each additional 30 minutes

MLFS Grade

F

Claims Administrator

Sedgwick Claims Management Services

Bill Review Vendor

Sedgwick CMS National Bill Review

Employer

Transdev

EOR

Adjustment Reason

G57 - This service requires prior authorization and none was identified.

Second Review Reason to dispute incorrect reimbursement

Claims administrator incorrectly denied reimbursement. For the medical-legal evaluation, adequate diagnostic tests were not included in the medical information (i.e. current and relevant test results) sent by the parties. To complete the medical-legal evaluation, the evaluator performed diagnostic tests. Per the DWC reimbursement is due for said testing: “A claims administrator must pay for a diagnostic test ordered by an AME or QME as long as the subjective complaints and physical findings that warrant the necessity for the test are included in the medical/legal evaluation report.” 96136 payment due: $68.25.  96137 payment due: S616.10. In addition to payment, penalties and interest are now due. An IBR will be filed upon failure to properly reimburse the diagnostic codes.


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