Pre - existing condition denial

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.