119: Benefit Maximum for this time period or occurrence has been reached
Denial Occurrence:
- Sometimes, there is a limit on a policy where certain services are allowed to pay only for a limited dollar amount or number of visits in a year or lifetime.
- When the insurance payment reaches that limit then this denial occurs.
- For example, if a service is limited to pay $1,000.00 in a year and a patient has already taken the same service 5 times in a year where the insurance has already made the payment of a total of $1,000.00. Now, if the patient goes for the same treatment again then insurance will not pay the claim this time and it will not get denied as the maximum benefit exhausted since the allowed dollar amount is already paid.
- For example, if a service is limited to pay for 5 times in a year and a patient has already taken the same service 5 times in a year where the insurance has made the payment for all the 5 times. Now, if the patient goes for the same treatment again then insurance will not pay the claim this time and it will not get denied as the maximum benefit exhausted since allowed visits are already paid.
On Call Scenario:
Claim denied as patient has reached
the maximum benefit allowed
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May I get the denial date?
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May I know maximum benefit reached in terms of dollar or visit?
↙ ↘
In terms of Dollar In terms of Visit
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How much Dollar amount How many Visit is
is allowed? allowed?
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How much dollar amount has How much visit has patient
patient met excluding this claim? met excluding this claim?
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Claim denied as patient has reached
the maximum benefit allowed
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May I get the denial date?
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May I know maximum benefit reached in terms of dollar or visit?
↙ ↘
In terms of Dollar In terms of Visit
↓ ↓
How much Dollar amount How many Visit is
is allowed? allowed?
↓ ↓
How much dollar amount has How much visit has patient
patient met excluding this claim? met excluding this claim?
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Has patient met the allowed dollar Has patient met the allowed visit
amount excluding this claim? excluding this claim?
↙ ↘ ↙ ↘
Yes No Yes No
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May I have the Could you please May I have the Could you please
claim# & call ref#? send the claim back claim# & call ref#? send the claim back
for reprocessing since for reprocessing since
patient has not met the patient has not met the
the allowed dollar allowed visits
amount excluding this amount excluding this
claim? claim?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
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May I have the May I have the
claim# & call ref#? claim# & call ref#?
Important Notes & Actions:
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May I have the May I have the
claim# & call ref#? claim# & call ref#?
Important Notes & Actions:
- Please take action as per your process update. Below actions can be different from your process update.
- If a patient has met the allowed dollar amount or visit excluding this claim then the claim must be billed to the secondary payer/consecutive payer or patient.
- Before billing the claim to a Secondary or Consecutive payer, need to verify the eligibility of the patient for the secondary or consecutive payer.
- To verify the eligibility of secondary or consecutive payers, check the payer website if access is available or else call the insurance.
- If a patient policy is active for secondary or consecutive payers on DOS then bill the claim.
- If no other payer is active or available on DOS then release the claim to the patient.
- When billing a claim to secondary insurance then do not change the payer sequence i.e. do not make secondary as primary and bill the claim or else the primary denial reason will not be sent to secondary insurance and the claim would be denied as need primary EOB.
- If the patient has not met the allowed dollar amount or visits excluding this claim and the rep send the claim back for reprocessing then set the follow-up for the TAT provided by the rep.
- Click here to go to Quiz
Prepare Notes:
Source of Status:
Clearing House Comment (Please make the changes if required):
Insurance Name:
Clearing House Name:
Insurance Phone#:
Rep Name:
Website Name:
Denial Date:
Maximum benefit reached in terms of:
Allowed Dollar Amount/No. of Visit:
Dollar Amount/No. of Visit met excluding this claim:
Has patient met the allowed Dollar amount/No. of Visit excluding this claim?:
TAT for Reprocessing:
Claim#:
Additional Comment:
Call Reference#:
Action:
In the below box, final notes will be displayed once you click on Submit button and this box is editable, so you can make the changes as per the requirement
Note: We are not saving your inputs in the backend.
will the secondary insurance pay the claim without primary payment details on this denial
ReplyDeleteIf the secondary insurance is not restricted to pay only deductible, coinsurance, or copayment and covers other out-of-pocket expenses then yes, there is a possibility of getting payment.
Deleteif claim denied as Benefit Maximum for this time period or occurrence has been reached then the whole amount wil applied as PR ???
ReplyDeleteYes, you can release the complete amount. However, the patient may not need to pay the whole amount. It is dependent on the provider, they can ask to pay only the allowed amount or maybe the whole amount in case of out-of-network.
Delete