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V55 Claim Denial Resolution

June 4, 2018

In November 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) implemented code-auditing enhancements to validate modifiers included on claims submitted to BCBSNM. This enhancement was announced in the News and Updates, as well as the Blue Review. You may have received a claim denial with the following message:

    (V55) After clinical review, the claim does not comply with coding protocol for the modifier submitted. Payment cannot be made due to coding practice utilized by this Participating Provider. Patient cannot be billed for the balance from this coding practice.

That message was recently updated:

    (V55) After review, the submitted modifier(s) could not be validated; payment cannot be made. Please submit records for further review. Patient cannot be balance billed for the disallowed code.

Thus, if you received denial code V55 and believe that the claim was denied incorrectly, you may request reconsideration by:

  1. Completely filling out the Claim Review Form found at bcbsnm.com/provider;
  2. Attaching any medical records that support use of the modifier; and
  3. Mailing the Claim Review Form and supporting medical records to the address listed on the Claim Review Form

You may also utilize the Claim Inquiry Resolution (CIR) tool within the Availity® web portal. For more information about how to access and use the CIR, please see the Claim Inquiry Resolution tip sheet found at bcbsnm.com/provider.

If you have any additional questions, please contact your Provider Network Representative at (505) 837-8800 or toll-free at 1-800-567-8540.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.