Florida Blue - Urinary Catheters?

[born2beflyin]

I'm looking into making a job change and getting Florida Blue 1424 for my special needs daughter (individual, child-only policy) who requires intermittent catheterization. Currently, her catheters are billed with HCPCS code A4351. Neither Florida Blue, nor CareCentrix, nor Edgepark will give me a straight answer whether or not her catheters will be covered. Florida Blue rep says she is "confident" they will be but that she couldn't guarantee it. The problem is urinary catheters aren't specifically mentioned in the contract as being covered nor excluded, so it's vague. Florida Blue rep says they should be covered under Durable Medical Equipment (DME), but our current Florida Blue plan (Federal) covers catheters under Medical Supplies in a separate section from DME in the contract.

HELP!!! I need an answer. Does anyone know if urinary catheters will be covered under Florida Blue plans, specifically 1424. Assume a preferred provider prescribed them, it's the cheapest solution, and they come from a preferred medical supply provider.

Thanks to anyone who can help.

Justin

 

[bluediamond]

Tell your FB rep to call 1 888 476-2227 this is called know before you go and she can either do that or call her agent service center and they can tell her. This is what she should have done in the first place.

 

[kgmom219]

Option #2

(I'm going to assume a 7/31 term date)

1. Apply for the child only policy for an 8/1 date.
2. Do NOT decline COBRA (there's a 45 day window from the date of the COBRA notice)
3. File a claim for the catheter in August under the new policy. If its covered, you're fine. If its not, you have time to activate COBRA, back to 8/1

Hope this helps!

 

[bluediamond]

Mom, you are correct, but he needed the agent to give him a concrete answer and the agent can make one or two calls and find a definite answer. I am not a 100% certain but on that particular plan probably is covered on DME, but he needs a definite answer.

 

[kgmom219]

Mom, you are correct, but he needed the agent to give him a concrete answer and the agent can make one or two calls and find a definite answer. I am not a 100% certain but on that particular plan probably is covered on DME, but he needs a definite answer.

And as an agent, I don't think he can get a 100% answer without the procedure and diagnosis codes and then ONLY if they will run a dummy claim. I damn sure wouldn't guarantee anything, even though I'm 99% sure. There needs to be a backup plan for his baby.

But I maybe a tad cynical and untrusting of carriers....

 

[born2beflyin]

Thanks for all the help.

I called the Know Before You Go line myself and they told me it would work just like my current Florida Blue Federal plan. Whether or not she really knew what she was talking about, I don't know, but she seemed quite sure.

As for the FB rep I've been working with, she said that was the first place she tried after I gave her the HCPCS code, but the answer she received included "refer back to the contract" which cites "medical necessity, cost effectiveness, etc." as part of the rationale for coverage. And that all makes sense, but I was looking for an answer that assumed it was a prescribed medical necessity provided by a preferred medical supply company. Maybe I wasn't clear when I asked the rep to check if it would be covered. I just assumed informing her that we get them now would cause her to assume they are prescribed, medically necessary, the most cost effective means, etc.

Thanks again all. I guess this will have to do since I don't think I'm willing to jump through the COBRA hoops explained above. EDIT: Now that I reread the COBRA explanation above, it would be a good idea to do that as a "safety net" in case things turn out badly.

 

[bluediamond]

I am glad you called that number, it has always been within $10.00 for any procedure and they have never told me to refer to the policy, they are polite and no wait while on phone. But mom is right about the cobra.