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Eligibility

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Eligibility, Payment, and Billing Procedures

* Describe a factor that determines patient benefits eligibility. * What are the appropriate steps to take when insurance does not cover a planned service? * Relate these steps to the eligibility factor you identified and provide two examples of patient charges with corresponding billing transactions.
Some factors that determine a patients benefits eligibility is their age, marital status, immigration status, healthcare needs, and work history. Also, if the patient works for a company that provides insurance, the insurance company may only cover the health care until a certain dollar amount, and then the patient is responsible for the rest.
The appropriate steps to take when the insurance plan does not cover the service that is planned for the patient is to first tell them! The patient needs to be told and explained to that the insurance plan does not cover their service that was planned and if possible, why it is not covered. Many people think that their insurance will cover many different services but, this is not always true. I am still unaware of what my insurance plan covers and does not cover completely. Then, the patient needs to be told that if they choose to continue with the planned service, the insurance company nor the provider will be responsible for the remainder of the bill. They need to be told that they will be responsible for paying the bill completely. Some choose not to go through with the procedure and others will.
EXAMPLES:
1. Service to be performed: Filling on decayed tooth
Estimated Charge: $100.00
Date of Planned Service: October 5th, 2014
Reason for Exclusion: Insurance does not cover the procedure
I, Melissa Luna, a patient of doctor Steinbach’s, understand that the procedure of a filling is not covered under by my insurance provider. I am responsible for full payment at time of service. 2. Service to be performed: Annual Exam
Estimated Charge: $50.00
Date of Planned Service: October 5th, 2014
Reason for Exclusion: Insurance does not cover annual exam
I, Minna Waters, understand that my insurance plan does not cover my annual exams. I am responsible for all payments due at time of service.

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