1: Deductible Amount

Scenario Occurrences:

• Deductible: It is a fixed amount that the policyholder needs to pay before an insurance company starts making payment for the treatment.
• For example, if a policyholder has a deductible of $2,000.00 and he/she undergoes a treatment that costs $1,500.00. So, when this claim is billed to insurance, it will apply toward the deductible and the policyholder will be paying this amount.
• If the policyholder undergoes for second treatment that costs $1,200.00 then this time insurance will apply $500.00 towards the patient deductible and process the remaining $700.00. When processing $700.00, it can also include patient responsibility as coinsurance or copayment based on the policy contract. The policyholder will be responsible for paying the deductible amount of $500.00.
• The deductible clause can be in terms of visit or dollar amount.
• If it is based on a visit then the policyholder will be responsible for full payment of the treatment cost until it reaches the allowed visit.

On Call Scenario:

                                                          Claim applied toward Deductible
                                                                                  ↓
                                                           May I have the processed date?
                                                                                  ↓
                                                          What is the Allowed Amount(AA)?
                                                                                  ↓
                                                How much is the total deductible limit on the policy?
                                                                                  ↓
                                                  How much has patient met including this claim?
                                               ↙                                                                              ↘
    If patient has met the deductible including this claim/                  If patient has already met the   
   Patient has not met the deductible including this claim               deductible excluding this claim
                                            ↓                                                                                         ↓
          Could you please fax the EOB? If not then mail it                     Could you please send the claim 
                 or provide the source to get the EOB?                                    back  for reprocessing since 
                                            ↓                                                                    patient has already met his
                  May I have the claim# & call ref#?                                     deductible excluding this claim?
                                                                                                                                       ↓ 
                                                                                                                    What is the Turn around
                                                                                                                 time(TAT) for reprocessing?     
                                                                                                                                       ↓
                                                                                                                      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.
• Once you receive the EOB through fax then note the account and send the EOB for posting and if EOB is sent to the mailing address then note the account.
• If the claim is sent back for reprocessing then you can set the follow-up for the TAT provided by the rep.
• Once the deductible is posted the claim can be billed to a secondary or consecutive payer. Before billing the claim to a secondary or consecutive payer, need to verify the eligibility of the patient for a secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payer, check the payer website if access is available or else call the insurance.
• If the patient policy is active for secondary or consecutive payers on DOS then rebill the claim.
• If no other payer is active or available on DOS then release the claim to the patient once the deductible is posted.
• When the claim is applied towards deductible by the Medicare payer then Medicare always forwards the claim to the consecutive payer. In this case, if the processed date crossed 30 days and we have not received any response from consecutive payers then call the insurance and verify the status.
• Sometimes the claim is processed as out of network then there is no need to take the adjustment and the full amount can be billed to the secondary or consecutive payer. If there is no other payer available then bill the amount 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:

*

Processed Date:

*

Allowed Amount:

*

Deductible Limit:

*

Has patient already met the deductible limit excluding this claim?:

* Yes No

TAT for Reprocessing:

*

EOB Available on Website:

*   Yes No

Source to get EOB:

* Fax Mail Website

Website Name/Link:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Resubmitted the claim Claim released to patient Posting required



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