Defy - Insurance covering bloodwork

When my primary physician won't prescribe HCG I talked to him about Defy. He agreed to run the lap work Defy required and turned the results over to them. Knock on wood it has worked for 6+ months so far.

When I have my Defy appointments I share that data with my Primary so he know's what Defy is doing with me.

Maybe your primary Doc would do the same.

New question - now I am having DHT rejected by insurance because the diagnosis code is not accepted. When I take to my doctor and ask him to change diagnosis code, he says no other code can be used...

Does anyone know much about coding and what is the correct diagnosis code to use in conjunction with the DHT blood test?

All my labs are marked with DX (diagnosicode) e29.1 which means "Testicular Hypofunction". Your lab order has to have a DX code on it or it will be rejected entirely. Was this in conjunction with other labs you had run or where you only having DHT pulled?

Vince Carter said:

All my labs are marked with DX (diagnosicode) e29.1 which means "Testicular Hypofunction". Your lab order has to have a DX code on it or it will be rejected entirely. Was this in conjunction with other labs you had run or where you only having DHT pulled?

Click to expand...

It was done in conjunction with other labs...

The used Procedure Code G0480 (which seems to be for drug tests...maybe this is the problem?) along with Diagnosis Code E291

Ive had problems in the lab with the abbreviation DHT, I have to take and write that out for the tech, DiHydroTestosterone, because they either can't find it or they select the wrong test.

Do u know which procedure code should be used? Or at least confirm that it should NOT be G0480

I think that that is what is also called a CPT code, if it doesn't jive with your insurance carrier it'll be rejected, by personal experience. Check this it shows a CPT code:

http://www.questdiagnostics.com/testcenter/TestDetail.action?ntc=90567

Vince Carter said:

I think that that is what is also called a CPT code, if it doesn't jive with your insurance carrier it'll be rejected, by personal experience. Check this it shows a CPT code:

http://www.questdiagnostics.com/testcenter/TestDetail.action?ntc=90567

Click to expand...

My insurance is calling it an HCPCS Code

Bump for anyone that might know anything...I have talked to insurance company, PCP and no one can help it seems...

MY LINK shows the same HPPCS code that you have above, G0480.

I will say this as it's reminiscent of my insurance rejecting my claims and such for these exact reasons...pay for stuff out of pocket (discountedlabs) and avoid the headache.

What a nightmare...thanks Vince Carter.

I ran into the same issue with my insurance (they don't cover out of state). The fact that they bill to the prescribing/referring doctor means they will check whether Defy (or whomever is the referring physician/medical facility) is considered to be in Network... if your plan doesn't cover out of state coverage, it won't be covered.

RVAwhat said:

I have Blue Cross Blue Shield. LabCorp is on contract with BC BS at each one of their locations across the country. The customer service rep from BC BS told me that they bill to the state of the prescribing doctor...

I might just try a different LabCorp location to see if each location does this.

Click to expand...

I am due for blood work so I've decided this time to try and find out what it will cost me ahead of time through my insurance. First I had to contact Labcorp, their customer service phone number is no longer on their web site. It is 1 800 631 5250. They were able to tell me how much they would bill BCBS for the tests and what the CPT codes for the tests are. The total they would bill BCBS came out to $1099. I then called BCBS and gave them the CPT codes, they said that if the services were billed in my home state the cost would be $160, but the CSR did not know, and could not find out in a short amount of time, what would happen if it was billed out of state, although she did confirm that out of state would still be covered under my plan. The CSR was going to kick it upstairs to the claims group to see if I can get an answer through them.

BTW, the same tests through Defy would cost $181, which is probably where I'll ultimately buy them.

Out of state or out of network? If it's out of *network you're going to pay more/insurance pays less.

Vince Carter said:

Out of state or out of network? If it's out of *network you're going to pay more/insurance pays less.

Click to expand...

Labcorp is in network. My insurance will cover labs ordered out of state, in this case form Defy, but it seems at a different rate than for in state labs. I'm trying to get an answer as to why that is.

Insurance is such a headache...best wishes!!!

I have had good luck contacting my BCBS plan via their website messaging system. I feel like at least you get a written response that you can then use if they bill you differently.

I'm sure it is a different plan, but I get 80% of labs covered at Labcorp regardless of the doctor prescribing. I get an Rx emailed from Defy, print it out, and take it. The statements seem to come from my local BCBS office, not Florida.

So my suggestion is to use the questions above and send them to BCBS. Their written response will hopefully be better than over the phone.

Good luck!

crazyhaha said:

I have had good luck contacting my BCBS plan via their website messaging system. I feel like at least you get a written response that you can then use if they bill you differently.

I'm sure it is a different plan, but I get 80% of labs covered at Labcorp regardless of the doctor prescribing. I get an Rx emailed from Defy, print it out, and take it. The statements seem to come from my local BCBS office, not Florida.

So my suggestion is to use the questions above and send them to BCBS. Their written response will hopefully be better than over the phone.

Good luck!

Click to expand...

Labcorp and Quest will both submit the claim listing the location of lab services as being Florida regardless of the state where the actual blood draw happened. It then gets processed under the rules of your plan that cover out of state services (unless your in FL). Hopefully this was made clear in your case.

I was actually told in writing by my local BCBS office that the reason I paid so much for my labwork is because Quest in Florida in not in my plan, but according to their website it is, so even the local agent who responded to my inquiry has no clue what is actually going on.

Thanks for this thread. So far, I have paid Defy directly for all my labs, but was considering just getting the Rx and having LabCorp bill insurance moving forward. It hit me a week or so ago that if I had been paying through insurance the same as what I've paid to Defy I would have already hit my deductible for the year and would only have to pay 20% moving forward. I assumed that since LabCorp is in-network in my state and several others, it would be covered.
.
Oddly, while LabCorp shows as in-network for my state and several other sample states for my Anthem BCBS plan, they DO NOT come up as in-network in Florida, meaning I'd probably be screwed from what I'm reading here. Even more confusing, Quest is showing as in-network both in my state and in Florida.
.
Bizarre and confusing. I guess I can either start using Quest (though HarryCat's experience has me worried there) or just continue paying the discounted Defy price.

Why not get your policy and read the section on blood test coverage? It should be spelled out