Issue: Pre-existing Condition
Action: Pre-existing condition refers to the terms & conditions entered into between the carrier and the patient / subscriber before the beginning of the contract. The rejection will usually say that the claim is being denied due to the pre-existing condition. It would not specify what exactly the condition is. So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything. (Ex.) A) There may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing that limit. If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition. B) There may be a condition that the carrier would not be paying for the same diagnosis more than once in a year. If a same diagnosis code is
used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating ‘pre-existing condition’.
As soon as you receive the denial, work order can be issued to Insurance calling. Check with insurance on the preexisting condition.
If the patient has secondary coverage: Check whether we can send the entire bill to secondary along with the primary denial. Some carriers may be willing to pay for the same. If the secondary agrees, bill the secondary along with the denial obtained from the primary.
If the patient has no Secondary Coverage / Secondary refuses to pay: Flip the balance to patient.
Pages
- Home
- Medical Billing Question and Answer - Terms
- Insurance Denial Claim Appeal Guidelines.
- Medical Billing Downloads
- Understand Medical Billing
- Medical Billing Outsource
- Medicare Coverage and Plan Overview
- Advertise with us
- EVALUATION AND MANAGEMENT CPT code [99201-99499] - Full List
- Overall Medical billing process
- CPT Code 99201, 99202, 99203, 99204, 99205 - Which code to USE
- Internal Medical Billing Audit - how to do
Medical Billing Popular Articles
-
Its often confused that BCBS have lot of prefixes and where to contact. However we have some guide to follow, using prefixes we could find t... -
Timely Filing Every insurance company has a time window in which you can submit claims. If you file them later than the allowed time, you ...
-
a. General Requirements When Medicare is the secondary payer, the claim must first be submitted to the primary insurer. The primary insure...
-
1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required mo...
-
CPT CODE AND Description 99391 - Periodic comprehensive preventive medicine reevaluation and management of an individual including an age...
-
CLINICAL RECORDS The following table contains general guidelines for clinical documentation that must be maintained by all providers excep...
-
CPT code and description 80050 - General health panel This panel must include the following: Comprehensive metabolic panel (80053), ...
-
Hyperlipidemia Hyperlipidemia (hyperlipemia) involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood. Hy...
-
When an ERA is received, providers may: •Post decision and payment information automatically, for individual claims included in an R... -
Denial code co - 45 - Charges exceed your contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total servic...
3 comments:
hi, im sorry i think pre-existing condition means, before giving policy insurer will check whether pt had any medical problem for long time, if pt had any problem then insurance will not cover for that procedure.
many insurance will check past 6 months to 18 months of pt record, if found any long term desease that procedure will not be covered.but still some insurance will not follow, but max insurance will follow this.
i think this is correct defination of pre-existing condition, if im wrong please correct me.
sorry, the pre existing definition here is very wrong.
Pre existing condition mans, if patient have the problem before the start of the insurance , then it is pre existing. The 5000 amount will be called deductible.It has nothing to do with pre existing.
You are wrong. When you dont have a correct idea about USHC(United States Health Care) why do you try to educate people....?
Please dont write anything that you dont have knowledge of.
Post a Comment