Client Impact: $350,000 in Paid Claims | Resolution Time: 1 year and 35 Days
The Challenge
A provider partnered with Missing Piece ABA Billing experienced claim denials from Blue Cross Blue Shield of Texas (BCBS TX) for CPT 97153, an essential ABA therapy code. While BCBS TX requires specific modifiers on these claims, all submissions were denied by the member’s home plan, Blue Cross Blue Shield of South Carolina (BCBS SC). The issue? BCBS SC expressly excludes behavioral health services rendered at the technician level, resulting in a direct policy conflict and full-scale denial of direct services rendered.
The Advocacy
Recognizing the broader implications for the entire ABA provider community, Missing Piece ABA Billing escalated the issue beyond standard billing appeals. We initiated contact with the BCBS interstate team, pressing for internal collaboration between the two state plans. To strengthen our position, we pulled and presented the Evidence of Coverage from BCBS SC, clearly demonstrating the policy contradiction.
Our advocacy wasn’t just on behalf of our client—it was on behalf of all providers navigating complex, multi-state BCBS relationships.
The Outcome
After sustained pressure and thorough documentation, BCBS TX and BCBS SC coordinated to resolve the policy conflict. Within 35 days of our intervention, all previously denied claims were processed and paid in full—resulting in $350,000 in recovered revenue for the provider.
The Bigger Picture
This resolution didn’t just benefit one provider—it established a precedent. Thanks to Missing Piece ABA Billing’s persistence and deep understanding of payer policies, BCBS TX now processes CPT 97153 claims more consistently for any providers treating SC members.
Conclusion
At Missing Piece ABA Billing, we don’t just submit claims—we advocate, intervene, and resolve systemic issues that affect the entire ABA provider community. This case underscores our role as a true partner in navigating the complexities of insurance reimbursement.