EstradaX_Week 4 IHMO Assignment

EstradaX_Week 4 IHMO Assignment - Xaira Estrada Week 4 IHMO...

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Xaira Estrada Week 4 IHMO There are many reasons why the claims could be returned by the insurance companies but today I will be talking about 3 of them. One reason is because the subscriber is not eligible at the time of the service. This means that at the time of the service the patient did not have active coverage, the patient will have to pay the balance, and a payment arrangement can be discussed. The patient could have given the outdated card at the time of the service and no one noticed it until the claim was done. Another reason why it can be denied is because coordination of the benefits/ primary EOB is needed. This means that the patient has a primary and secondary insurance and many time the secondary payer will deny the claim if it is summited without the primary EOB information. They have 2 options either attach the primary information
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Unformatted text preview: can be a²ached to the claim electronically or it may happen to be that it is not an op±on and it will have to be added manually to the primary EOB to a paper claim and re-billed to the secondary. The third reason is having a max frequency or beneFt is reached for the person ge³ng the service such as rou±ne services or an immuniza±on. In this case the Frst ac±on to take should be to call the payer (which is the insurance company) and ensure that the claim was processed correctly. If the medical professional feels that the service was rendered due to medical necessity regardless of the frequency, the provider should appeal the denial with suppor±ng medical documentary....
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  • Fall '15
  • insurance companies, insurance company, Xaira Estrada, primary EOB

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