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Eligibility, Payment, and Billing Procedures

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Submitted By Darlitta
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Eligibility, Payment, and Billing Procedures
Darlitta Rose Shepard
HCR/220 Claims Preparation: Clean bills of Health
10/11/2015
Lydia Cavieux

Eligibility, Payment, and Billing Procedures * Describe a factor that determines patient benefits eligibility.
Verify the patient’s eligibility for benefits. As a medical insurance specialist you are to abstract information about the payer/plan from the patient’s information form (PIF) and the insurance card.
Then contact payer to verify three points: 1. Patients general eligibility for benefits 2. The amount of the co-payment or coinsurance required at the time of service. 3. Whether the planned encounter is for a covered service that is medically necessary under the payer rules.
These items are checked before an encounter, except in a medical emergency when care is provided immediately and insurance is check after the encounter. * What are the appropriate steps to take when insurance does not cover a planned service? As a medical insurance specialist attempt to determine whether the planned encounter is a covered service. If the service will not be covered, that patient can be informed and made aware of financial responsibility in advance. * Relate these steps to the eligibility factor you identified and provide two examples of patient charges with corresponding billing transactions. According to our reading Ch.3 Medical insurance.
As a slightly older woman I can relate to the both. I have called my clinic to set up an appointment to see the doctor about for my knees, they checked me in, and I was evaluated by my physician and sent me for x-rays and after his diagnosis he gave me a referral for physical therapy. After the visit, the medical insurance specialist uses the documented diagnoses and procedures to update the practice management program and to total charges for my visit.…...

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