Date
Attn:
Patient:
Policy:
Insured:
Treatment Dates:
Amount:
Dear Director of Claims,
We are in receipt of your payment for the above referenced claim. However, it is our position that your company failed to reimburse properly for this treatment.
According to the Current Procedural Terminology (CPT), there are three distinct components of global maternity care: antepartum care, delivery and postpartum care. CPT states that any complications or signs and symptoms that occur during the OB package, related or unrelated to the pregnancy, inpatient or outpatient, are outside the global period and reported separately using the appropriate E/M codes based on medical record documentation. The American Academy of Family Physicians supports the principles of CPT and believes that health plans should abide by these principles.
It is our position that this E&M service was outside the routine global maternity package and billed with the appropriate modifier indicating an unrelated service. Further, this additional care was required to provide this patient with optimum care and should be fully compensated.
Please reprocess this claim allowing benefits for the E&M service. If no additional benefits are released, we appreciate your written response to this appeal with supporting documentation from any nationally published coding guidelines or any applicable internal policy guidelines.
Sincerely,
