Case Study: Resolving Anthem Blue Cross Blue Shield Amerigroup Pre-Payment Review on NST Studies

In this case our client faced a complex issue with Anthem Blue Cross Blue Shield Amerigroup regarding NST (Nuclear -Stress Test) studies. The insurance company had placed a pre-payment review on all NST claims submitted by the provider, flagging them for additional scrutiny. Here’s how our team tackled the problem. 

The Initial Problem 

After submitting the necessary documentation for the claims, Anthem Blue Cross Blue Shield Amerigroup denied payment for the A9500 pharmaceutical code, which is essential for conducting the NST test. The denial was based on a seemingly illogical rationale: the insurer claimed that the test itself was missing despite the fact that the procedure had been billed correctly and was even approved after documentation review. 

Step 1: The First Appeal