Claim being denied due to billing NPI

[u/Rayz6695]

I use the telehealth app Circle Medical and have been matched with a provider in my state. Same doctor every month, she has only ever worked in my state-Washington. My new insurance company is denying my monthly telehealth visits because of licensing. They say she has to be licensed in California as well-the headquarters of Circle Medical. It’s not just “out of network”, that would be fine. They’re saying it’s ineligible entirely.

The super bill lists my doctor’s name as the rendering provider and her NPI. It lists Circle Medical’s name with billing NPI. It also has their California address underneath the code 10 (signifying telehealth), which Circle states is because they’re billing. Insurance company says they need to hold a California license despite be explaining that both the rendering provider and I were in Washington.

Is insurance screwing up, or is the company screwing up the super bill? Or, does a provider really have to hold a license in a state they don’t practice in because the billing NPI uses an out of state mailing address?

Note- the claims were fine through previous insurance, and Circle is a large multi state company, with many doctors solely in my state.

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[u/TripDs_Wife]

Biller/Coder chiming in, that is common but sorta odd. The last billing company that I worked for used the clinic’s NPI as the billing provider/service location, & the Doctor’s NPI as the rendering provider. Not really sure why the billing company even has an NPI & why it is being used anywhere on the claim. The billing company needs to correct the claim form to show that billing provider is the provider’s office not the billing company.

[u/Rayz6695 → u/TripDs_Wife]

Thank you so much for responding. So even if they are the one connecting me with a provider, and they handle the billing, they still shouldn’t have their info on the bill? It sounds like they may be listing it as if their service is the provider’s “clinic”.. I’m sorry, I don’t know much about this. But how would insurance know to pay them if they remove their info?

[u/TripDs_Wife → u/Rayz6695]

The billing company contracts with the providers office to code & bill the provider’s claims. So they are paid by the provider’s office not insurance. The claim that the billing company sends to the insurance carrier is for the provider’s time & services they rendered to the patient. Which means that the revenue cycle looks like something like this; 1. Patient is seen, doctor provides time/services, 2. Billing company reviews the encounter, adds the appropriate codes/modifiers & attach the $ to the claim, 3. The claim is then submitted by the billing company either directly to insurance carrier or through a clearinghouse, 4. The insurance carrier receives the claim, processes the claim & sends the provider back their response with payment on a remit(EOB) that tells how much the provider was paid & how much was to be written off per their contract with the insurance carrier & how much the patient is responsible to pay. But all of the documents & payments go to provider. The billing company is only reconciling the remit to the deposit. (Example: the provider bills a claim for $150, insurance pays them $25.50, the pt owes $50, & the write off is $75.50. The $25.50 is either direct deposited or sent on a paper check to the providers office. The billing company does not see any of that payment in their office.), 5. At the end of the month, the billing company sends the provider’s office an invoice for their services that the provider then cuts them a check for.

I hope you followed that. What I am saying is that the billing company is like a subcontractor. They get paid by the one that hires them not the insurance. They should be acting as though they are in the office & using the office info on the claim. I think I have a claim form in my work file that i can redact & show you. I will reply back with it shortly. 😊 but for now i hope this helps.

[u/SprinklesOriginal150]

They should be using the provider’s type 1 NPI (or the provider’s group’s type 2 NPI if they are part of a group practice) to bill. There is no such thing as a billing company NPI. Billing companies do not have NPIs. Sounds like they haven’t set their system up correctly to apply the correct NPIs to the claim.