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
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:
& 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:
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:
Policy Termed Date:
Is Policy Active on DOS?:
TAT for Reprocessing:
Is there any other active policy on DOS?:
Policy ID of active coverage:
Eff date of active policy:
Is policy still active?/No Termed Date:
Termed date of active policy:
Additional Comment:
Claim Number:
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.
good luck
ReplyDeletehey AR learning as a user of your given information or help that is so useful for us and for me. as you help in preparing notes in your inbar just wanted if u can add one more thing is action to taken on that note like just co relations or something. e.g. set up follow up date,resubmit,or corrected claim these things. ty
ReplyDeleteWe have already added the 'Action' field to select the appropriate action in the 'Prepare Notes' section. Are you looking for this? Or else can you please explain in more detail or give an example of what you are looking for?
DeleteHi AR Learning,
ReplyDeleteIf the member is inactive coverage was terminated and we found another insurance in system which is secondary, can we directly bill to the secondary insurance? as there is no primary insurance which is active, or the other Insurance needs to be primary only? or does member need to update his cob in order to secondary insurance to act as primary now?
You can check the eligibility of secondary insurance for your DOS. As per secondary insurance if other insurance is primary on DOS which is inactive then it needs to be billed to the patient to update the COB.
DeleteIf secondary insurance is not showing any other insurance as primary then you can submit the claim to secondary insurance after making it primary.
Hi AR Learning
ReplyDeleteWhat is difference between Plan begin date and coverage begin date.
Coverage begin date is the date when the insurance company starts covering and paying for your medical expenses.
DeletePlan begin date is the date when the patient is enrolled into a particular benefit plan.
Best App i have ever seen
ReplyDelete👍
DeleteHi if the patient's has secondary coverage with commercial insurance and it make patient responsibility after that we can submit the liability towards patient or not?
ReplyDeleteYes, you can if there is no tertiary insurance.
DeleteWhy can’t we bill the Medicaid patient?
ReplyDeleteYou can bill Medicaid patients. But, there are different guidelines based on the states that need to be followed. Please confirm with your client if it is allowed to bill Medicaid patient or not.
Delete