If a payer denies payment and the adjustment codes shows that the procedure is not covered by the policyholder's plan, what is the next step?
Added by Teresa M.
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This document should detail why the payment was denied and which adjustment codes were used. Show more…
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If an insurance company denies payment for a procedure listed on a claim, what steps should the insurance specialist take? Think about the process of what happens to a remittance advice after it is received from an insurance company. What are the possible solutions to a denied claim?
Bibi N.
You receive an EOB for a patient who is covered by an HMO. The HMO did not pay for services received on May 5, which is when the patient visited Dr. Larsen for her annual Pap smear. You check your records and find that the same insurance carrier paid for previous Pap smears for the same patient in past years. What should you do?
Adi S.
Liu Huang was seen for an outpatient visit at the Central Clinic and received a glenohumeral joint injection during the appointment. A claim was created for this visit and procedure and submitted to Liu's insurance company. The insurance company provided Central Clinic with the below Remittance Advice (known as an Explanation of Benefits (EOB) when provided to patients), indicating what they covered, and they also submitted payment for their share through Electronic Fund Transfer (EFT). Review the submitted claim under the Account section of Liu's chart. Then update the ledger to indicate the insurance adjustments and payments. Additional info: Liu has met his annual deductible. Any Provider Charges that exceed the insurance company's Allowed Charges were discounted and adjusted by the insurance company – neither the insurance company nor the patient will be responsible for any amount exceeding the Allowed Charges in this situation, and the provider will not receive payment for this amount. The insurance company then pays 80% of the Allowed Charges, and the remaining 20% is Liu's responsibility as coinsurance. Enter Provider Responsibility amounts as adjustment transactions from the insurance company as a credit without a balance transfer. Enter Paid Amounts as payer payments via EFT.
Akash M.
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