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
                                                                               ↓
                                                            May I get the denial date?
                                                                               ↓
                            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?
                                   ↓                                                                                   ↓

         Has patient met the allowed dollar                            Has patient met the allowed visit

            amount excluding this claim?                                          excluding this claim?

                 ↙                             ↘                                                    ↙                                ↘

            Yes                                  No                                        Yes                                      No

              ↓                                     ↓                                           ↓                                         ↓

   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?
                                                    ↓                                                                                       ↓
                                         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:

* Call Website EOB System

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:

* Dollar Amount Visit

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?:

* Yes No

TAT for Reprocessing:

*

Claim#:

*

Additional Comment:

Call Reference#:

*

Action:

* Resubmitted the claim Claim released to patient Need client assistance



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