ML201 / MLPRR - Sedgwick Claims Management Services: Grade F

ML201 / MLPRR - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML201 and MLPRR. Sedgwick incorrectly denied valid medical-legal codes as “not in the fee schedule.” Date of Service: 04/06/2021

MLFS Code(s)

ML201 - Comprehensive Medical-Legal Evaluation

MLPRR - Record Review

MLFS Modifier(s)

95 - Evaluation performed by a panel selected Qualified Medical Evaluator

96 - Evaluation performed by a Psychiatrist or Psychologist when a psychiatric or psychological evaluation is the primary focus of the medical-legal evaluation

MLFS Grade

F

Claims Administrator

Sedgwick Claims Management Services

Bill Review Vendor

Conduent

Employer

The Salvation Army

EOR

Adjustment Reason

549 - The service(s) on this claim have been denied because the provider billed using a procedure code that is not in the fee schedule

Second Review Reason to dispute incorrect reimbursement: ML201

Claims administrator incorrectly denied reimbursement. Per CCR §9795, ML201 is valid reimbursable procedure code that includes all comprehensive medical-legal evaluations that do not qualify as follow-up or supplemental medical- legal evaluations. Provider conducted a Comprehensive Medical-Legal Evaluation at the request of the parties. ML201-95-96 payment due: $4,030.00. In addition to payment, penalties and interest are now due.

Second Review Reason to dispute incorrect reimbursement: MLPRR

Claims administrator incorrectly denied reimbursement. Per CCR §9795, MLPRR is a valid reimbursable procedure code used to identify charges for review of records in excess of pages included in medical-legal numerical billing codes. Excess pages are billed at three dollars per page. Provider documented record review page count in report. MLPRR payment due: $1,968.00. In addition to payment, penalties and interest are now due.


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