242: Services not provided by network/primary care providers (Provider is Out of Network)

Denial Occurrence:

• This denial occurs when the provider who rendered the service is not contracted with the insurance.
• In this scenario, the claim can be paid if the patient's policy covers out-of-network benefits.
• If the patient's policy does not cover out-of-network benefits then the claim can be billed to the patient.
• In the HMO or EPO plan, out-of-network benefit is not covered.
• In the PPO or POS plan, out-of-network benefit is covered.

On Call Scenario:

                                                    Claim denied as non covered services
                                           as per patient plan as provider is out of network
                                                                                ↓
                                                             May I get the denial date?
                                                                                ↓
                                             Does patient plan cover out of network benefit?
                                                                                ↓
                                         What plan does patient has? (HMO, PPO, EPO, POS)
                                      ↙                         ↙                      ↘                           ↘
                                  ↙                         ↙                              ↘                           ↘
                            HMO                   PPO                              EPO                        POS
                           ↙                             ↓                                    ↓                                 ↘ 
       May I have the             Could you please             May I have the                  Could you please

    claim# & call ref#?        reprocess the claim        claim# & call ref#?             reprocess the claim

                                            since patient plan                                                       since patient plan
                                            does cover out of                                                       does cover out of  
                                            network benefit?                                                         network benefit?
                                                        ↓                                                                                  ↓
                                            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 the claim is denied as non-covered charges under the patient plan as the provider is out of network and the patient has a PPO or POS plan and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the claim is denied as non-covered charges under the patient plan as the provider is out of network and the patient has an HMO or EPO plan then bill the claim to the secondary or consecutive payer if available or else release it to the 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 no other payer is active or available on DOS then release the claim to the patient.
• 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:

*

What is patient plan?:

* HMO PPO EPO POS

TAT for Reprocessing:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Claim released to patient Resubmitted the claim Need to allow time Need client assistance



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