Benefit exhausted - Denial and action

Coverage not Valid for DOS/Coverage Terminated/ Benefits Exhausted:

All these are patient related. However if we had effective dates of each coverage established, then the first two kinds of errors can be identified at the front end itself before the claims are generated. As regards the last one i.e. Benefits exhausted, this may be due to the fact that the patient’s policy will pay for a particular procedure only once during a year or once during a life time or the insurance company’s general rule

for a particular procedure may be only once reimbursable. If it is latter setting up a billing rule for that procedure and that insurance company can identify it beforehand. If it is patient policy specific, then this can be known only when we receive the denial. The ultimate solution for all these cases is to bill the patient.

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