ML201 - Guard Insurance Group: Grade F

ML201 - Guard Insurance Group: Grade F

Claims administrator failed to properly reimburse ML201. Guard incorrectly incorrectly reduced reimbursement by taking a noncompliant PPO reduction. Date of Service: 04/17/2021

MLFS Code(s)

ML201 - Comprehensive Medical-Legal Evaluation

MLFS Modifier(s)

93 - Interpreter needed at time of examination

95 - Evaluation performed by a panel selected Qualified Medical Evaluator

MLFS Grade

F

Claims Administrator

Guard Insurance Group

Bill Review Vendor

Guard Insurance Group

Employer

Felix Gardening & Landscaping

EOR Adjustment Reason

G4 - This charge was adjusted to comply with the rate and rules of the contract indicated.

Second Review Reason to dispute incorrect reimbursement

Claims administrator incorrectly reduced reimbursement. Medical Legal services are not subject to PPO / Network Reductions. Per CCR §9795, ML201 reimbursement is $2,015. With Modifier 93, the value for the procedure is modified by multiplying the normal value by 1.1, totaling $2,216.50. ML201-95-93 payment due: $221.65. In addition to payment, penalties and interest are now due.


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