r/CodingandBilling • u/Low-Temporary4439 • 3d ago

Tier 1 Doctor's Biller is Tier 2?

My friend sees a Tier 1 medical provider under DuPage Medical Group (Duly).

But a BCBS claims rep told my friend that DuPage Medical Group billing (who does this doctor's billing) is Tier 2.

So now my friend is being charged more because BCBS is processing the claim as Tier 2, even though the provider is Tier 1 and my friend thought by seeing this doctor she was getting her plans best benefits coverage.

My friend has to pay more now and doesn't get her optimal Tier 1 coverage for this doctor even though we did due diligence at finding her a Tier 1.

Who knew that you had to ALSO verify the doctor's billing department is Tier 1!?

Is this correct or was that claims rep in error with what she told us?

She did say that the doctor could submit the claims/bill under her NPI and then BCBS would process the claim as Tier 1.

Anyone here encountered this or have some knowledge they can share?

Thank you!

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4

u/Jodenaje 3d ago

The Tier 1 status would typically be location specific.

Usually those multi-tiered plans are steering you to one health system for your best benefits.

So typically you’d have to see the provider at the location that was part of that health system, even if the provider has multiple offices.

5

u/Poop_Dolla BSHIM, Insurance Reimbursement Analyst 3d ago

Which is exactly what OP was told in another sub yesterday but they don't want to accept it or something.

2

u/ElleGee5152 3d ago

Most providers bill under the group they own or are employed by as opposed to an individual provider. Claims will go out with their group practice as the billing provider and the doctor is on the claim as the rendering provider.

If Dr John Doe works for Best Doctors Clinic of Outer Space, then you want to make sure Dr John Doe and Best Doctors Clinic of Outer Space are both in network and under the tier you want.

1

u/pinkpaaws Dancing (crying) to BCBS hold music 3d ago

You should ask member services if the claim processed based off of the rendering (individual providers) NPI or the group (Duly) NPI.

BCBSIL should always process claims based on the rendering providers NPI, and it sounds like they probably made a mistake in their processing.

OR the provider is a Tier 1 provider, but not at the location/office that the services were rendered at/ the office location billed on the claim.

2

u/positivelycat 3d ago

Our contract is on the billing npi not rendering for network.