26: Expenses incurred prior to coverage/27: Expenses incurred after coverage terminated

Denial Occurrence:

• This denial occurs when the service is performed on a date that does not lie between the policy effective date and the policy termination date.

On Call Scenario:

                                                          Claim denied as member coverage
                                                              terminated or Policy termed
                                                                                  ↓
                                                                May I get the denial date?
                                                                                  ↓
                                                May I have the policy effective and termed date?
                                                                                  ↓
                                          Check if DOS lies between effective and termed date
                                            ↙                                                                                  ↘
                                        Yes                                                                                    No
                                          ↓                                                                                       ↓
                     Could you please send the                                                   Is there any other policy    
                    claim back for reprocessing                                                active for patient on DOS?
                    since policy active on DOS?                                              ↙                                 ↘
                                         ↓                                                               Yes                                    No

                           What is the TAT for                                                 ↓                                       ↓

                                reprocessing?                                May I have policy ID,               May I have the

                                        ↓                                              Policy effective and              claim# & call ref#?

                          May I get the Claim#                                 termed date?

                               & Call ref#?                                                   ↓

                                                                                       May I have the claim#
                                                                                              & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the rep sends the claim back for reprocessing then you should set the follow-up for the TAT provided by the rep.
• If the rep finds another policy that is active on DOS then you can update the new policy ID and resubmit the claim.
• If the policy is inactive and there is no active policy on DOS then you can release the claim to the patient.
• Before releasing the claim to the patient, check if any other insurance is available or not.
• When other insurance is available then check eligibility for that insurance on the web portal if access is available and if the patient is active for that insurance as primary then make it primary and resubmit the claim.
• Always check previous DOS, if payment from any other insurance was received or not. If yes, then check the eligibility for that payer for DOS and resubmit the claim if the patient policy is active.
• 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:

*

Policy Effective Date:

*

Is policy still active?/No Termed Date:

* Yes No

Policy Termed Date:

*

Is Policy Active on DOS?:

* Yes No

TAT for Reprocessing:

*

Is there any other active policy on DOS?:

* Yes No

Policy ID of active coverage:

*

Eff date of active policy:

*

Is policy still active?/No Termed Date:

* Yes No

Termed date of active policy:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Resubmitted the claim Updated the policy details and resubmitted the claim Claim released to patient Need to allow time Need client assistance



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