Do You Know The Code?

If you are trans you need to know the code!

I lost count of the numbers of times that I had to give out the code, but you can learn it yourself.

The code is for gender override for Medicare and Medicaid so that a claim of mismatched gender will get processed instead of getting kicked back and denied.

There is a good webpage on the Center of Excellence for Transgender Health website that was written by Andre A. Wilson, MS; Jamison Green, PhD that explains how to get coverage for procedures that have been denied by your insurance provider.

Claim denials for sex-specific procedures
In some automated systems, if for example the patient is designated as "female" in the electronic record (EMR), and a treatment or procedure code is entered for care that is exclusively covered for bodies designated male [e.g., prostatic ultrasound]), that claim may be automatically rejected. The reverse would be true for someone designated as "male" in the EMR but who requires care that is exclusively covered for bodies designated "female." If the patient's plan document or individual state regulations provide that transgender care is covered (or that care may not be restricted on the basis of sex), then the patient may need support from the physician's office to inform the carrier or administrator that the patient is transgender, and that this claim cannot be rejected. If there is no provision for transgender care in this instance, it will be necessary for the provider to appeal to the carrier for coverage of the specific treatment or diagnosis.

And therein lies the problem for us gals our annual prostrate exam and for the guys their PAP smears might not be covered so you are going to have to advocate for yourself with your insurance provider.

Overriding a "sex mismatch": condition code 45
All federally-funded health institutions (e.g., most hospitals) have received instruction on the use of Code 45 (and the KX modifier) in their coding practices and all Medicare Administrative Contractors are required to process this code,[6] which is an override for a sex mismatch. However, the code may not have been implemented by all hospitals or carriers' systems; in these cases using Code 45 may result in a returned claim for correction, or outright denial of the claim.

That is the secret code so spread the word!

You can read the actual CMS policy “Pub 100-04 Medicare Claims Processing”

And if your claim is still denied…

Claims denials and discrimination
Many transgender people experience denials of their claims for transgender transition-specific services. Many more never receive a formal denial because their plan contains transgender-specific exclusions and the physician never files paperwork for prior authorization for such services. Many call their insurance carrier and are told services will not be covered, and on that basis never attempt to file a claim. Transgender individuals and their health providers should be aware that unless a denial is in writing, it is not a denial and cannot be appealed. More importantly, transgender individuals with well-documented claims are increasingly achieving success in their appeals. Individuals are encouraged to work proactively with their medical providers to ensure that appeals documents include individualized, extensive documentation of the necessity and appropriateness of services. Such appeals should also include a comprehensive and detailed overview of the process of gender transition, including the role of and evidence in support of the specific services requested. In addition to providing a background to uninformed reviewers, such comprehensive documentation conveys the individual's intent to pursue the appeals to the final stages, which can be quite persuasive.

And if that still doesn’t work you can hit them with a metaphorical two-by-four with filing a claim of discrimination under the ACA section 1557.

Section 1557 of the Patient Protection and Affordable Care Act
Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Section 1557 builds on long-standing and familiar Federal civil rights laws: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. Section 1557 extends nondiscrimination protections to individuals participating in:

• Any health program or activity any part of which received funding from HHS
• Any health program or activity that HHS itself administers
• Health Insurance Marketplaces and all plans offered by issuers that participate in those Marketplaces.

Section 1557 has been in effect since its enactment in 2010 and the HHS Office for Civil Rights has been enforcing the provision since it was enacted.  If you believe you have been discriminated against on one of the bases protected by Section 1557, you may file a complaint with OCR.

For those who are covered by Medicare,

How to file a complaint (grievance)You can file a complaint if you have a concern about the quality of care or other services you get from a Medicare provider. How you file a complaint depends on what your complaint is about.

If you do not have coverage under Medicare/Medicaid or ACA you can file a discrimination complaint with your state insurance commission.

If you have insurance under ERISA… well you are out of luck. You could possible file a discrimination complaint with the EEOC.