Not covered when performed during the same session/date as a previously processed service for the patient.
A. Need to check in the system whether the same type of service was billed previously for the same Dos.
B. Need to confirm any global period was applicable for this particular service.
C. If both criteria is not applicable, Call Insurance and discuss the denial status in detail and send back the claim for review if it was incorrectly denied.
Expenses incurred after the coverage terminated.
A. Check with Insurance for any other active Insurance coverage details. Sometimes, the pt coverage is active with New Mem Id# under same Plan. If it’s the case, then update the New Mem Id# and refile the claim.
B. Check whether new Pt card copy was received/scanned in the system. If it’s available then file the claim to
New Insurance after checking the eligibility details.
C. Call patient and check for active coverage details or else bill patient.
Your plan does not cover this visit, consultation, E&M or associated expenses.
A. Call Insurance and confirm the Office visits/Consultation are not covered under patent’s plan.
B. Call patient and check any other medical coverage is available or else bill patient.
Maximum preventative has been satisfied.
A. Check the total dollar amount available for physical examination codes per calendar year.
B. Call Insurance and chk whether pt met the whole amt.
C. If the amt was not met in full, send back the clm for review.
D. If the amt was met in full, bill pt for the balance amt.
No coverage for out of network providers.
A. Check the old claims for the patient whether it was processed previously by this carrier.
B. Bill patient for the balance.
Other Insurance is Primary.
A. Call Insurance/Verify online to confirm whether the other Insurance is primary and also get the effective date.
B. If the Dos falls within the effective date, update/change the other Insurance as Primary and file the claim.
Maximum benefits reached.
A. Check the total dollar amount for the visits per calendar year and how much the pt met so far.
B. If amount was met in full, bill patient for the balance.
C. If amount was not met in full, ask to send the clm for review.
Claim denied for COB Info
A. After receiving this denial, call Insurance and check the COB info was updated. If it’s updated, inquire about the current status.
B. If the COB info was not updated, Call patient and inform to update the COB info with Insurance.
Non Covered charges – Coverage only for Medicare Part A Benefits
A. Check with Medicare card copy/Insurance and confirm medical benefits was not available for the patient.
B. If it’s not available, check for any other active coverage or else bill patient.
Your contract excludes this procedure or condition as a covered benefit.
A. Check/Consult with the coding dept., whether the submitted diagnosis code was compatible with the patient condition.
B. If it’s not compatible, get any other alternate & related diagnosis code from the coding dept and refile the claim.