51: These are non-covered services because this is a pre-existing condition

Reason for Occurrence :

• When a patient is already suffering from any disease (for example - Asthma or Diabetes) and he/she wants to buy a new policy then insurance can deny covering the disease that a person already has because chances for claims of that disease will be high.
• This already existing disease comes under pre-existing conditions.
• Some insurances may cover this condition but policy premiums will be very high and there will be some waiting period that the patient needs to wait before getting the insurance benefit. for example - If the patient is having a pre-existing condition for Asthma and the waiting period is 6 months then when the policy starts, the patient needs to wait for 6 months before insurance provides coverage for Ashthma claim.
• If a claim for a pre-existing condition is billed within the waiting period then insurance will deny that claim stating non-covered services as this is a pre-existing condition.

On Call Scenario:

                                        Claim denied as pre-existing condition not covered
                                                                            ↓
                                                          May I get the denial date?
                                                                            ↓
                                   What are the start and end dates of the waiting period?
                                                                            ↓
                      Check DOS lies between start and end date of waiting period (WP)
                                       ↙                                                                     ↘
                                   Yes                                                                       No
                                     ↓                                                                          ↓
             May I have the claim# & call ref#?                Could you please send claim back for
                                                                                   reprocessing since DOS lies outside of 
                                                                                                       waiting period?
                                                                                                                 ↓
                                                                                       What is the TAT for reprocessing?
                                                                                                                 ↓
                                                                                       May I have the claim# & call ref#?

Important Note:

• If DOS lies between the start and end date of the waiting period then bill the claim to the patient.
• Do not bill the claim to a secondary or consecutive payer since they are not going to process the claim.
• If a patient has any other primary insurance coverage then the claim can be billed to that insurance.

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:

*

Start Date of WP:

*

End Date of WP:

*

Is DOS lies within waitin period?:

* Yes No

TAT for Reprocessing:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

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



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