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
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May I get the denial date?
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Does patient plan cover out of network benefit?
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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 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:
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:
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?:
TAT for Reprocessing:
Additional Comment:
Claim Number:
Call Reference#
Action:
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This is very helpful. Thank you
ReplyDeleteif the provider is In-network and patient plan is POS. What will do on it?
DeleteSimply ask to reprocess since in-network providers are covered in all kinds of insurance plans including POS.
DeleteThanks for your response.
DeleteThanks for your comment.
ReplyDeleteIt's very helpful concept for me.
ReplyDeleteGood to hear that Upendra. Thank you.
DeleteVery helpful thanks!!
ReplyDeleteThanks alot
ReplyDeleteHow about asking the patient to change his PCP?
ReplyDeleteFor future claim, you can give suggestion to patient to visit a provider who are in network with the health insurance to avoid such denial where patient will need to pay additional money.
Deleteif secondary not covered the hmo plan what the next step to do
ReplyDeleteWhy is it not covered? Can you please provide more details on this?
DeleteHelpful thankyu
ReplyDeleteThank you.
DeletePR-242 GIVEN BUT IN LEDGER ITS NOT SHOWING THE BALNCE AMOUNT DO YOU KNOW ANY IDEA
ReplyDeleteCan you please let us know what information are available in the ledger? For example: allowed amount, paid amount, PTR etc.
Deletecan you please tell me about the deneid of pcp the provider is inrolled with payer 4/01/2023 called to insurance said that the privious pcp is different so can't reprocess the claim in this senerio what should i do for this claim
ReplyDeleteIf the date of service is prior to 04/01/2023 and PCP is correct then it is a credentialing issue that needs to be resolved.
DeleteBut, you can check the patient plan, if it is PPO or EPO then a PCP visit is not required and the claim can be reprocessed.
very helpfull
ReplyDeleteThank you!
DeleteWill secondary insurance pay these type of claims when there is no Copay/Deductibles/or Coins where the primary has denied due to 242? or do we need to apply medicare allowed amount?
ReplyDeleteIt depends on the policy contract with secondary insurance. Sometimes, secondary insurance is only allowed to pay deductible, coinsurance or copayment. In that case the claim will get denied.
DeleteBut, if the secondary insurance is responsible to cover other services as well. In that case, if the primary insurance denied the claim as provider is out of network then secondary insurance may pay the claim for the amount that they are responsible if provider is in network for them.
Good source of knowledge for AR
DeleteThanks!
DeleteThis charge is a duplicate of a previously processed claim.
ReplyDeleteIf you have received this denial on a claim then you can follow the below scenario to work on it.
Deletehttps://www.arlearningonline.com/2019/11/18-exact-duplicate-claimservice.html
scenario denial is for charge exceeds as per fee schedule/ maximum allowable ????????????
ReplyDeletePlease refer the below post,
Deletehttps://www.arlearningonline.com/2023/04/how-to-wok-on-denial-code-45.html
what if the provider is inactive for dos let's say dos- 03/01/2024. The provider was active till 02/28/24 and was inactive from 03/01/2024-04/30/2024 and again active from 5/01/2024 and also if the provider is never contracted with the payer?!....will this go for credentialing issue?
ReplyDeleteYes, this is a credentialing issue, as the provider was not active or contracted with the payer on the date of service.
DeleteThe claim denied for Auth as Dr is Out of network. if we change the dr name into other dr name who is in-network with plan will it be considered as fraud billing ?
ReplyDeleteYes, it will be. You must mention the doctor who provided the service. If the doctor is out of network, you should work to make the doctor in-network to avoid denial of future claims.
DeleteYou can also try to verify whether patient plan covers out-of-network benefit. If it does not then you can bill the claim to patient and if it does then auth would not require.
Are you applying the discounts?
ReplyDeleteCould you please clarify your question a bit more?
Delete