Eligibility

Eligibility, Payment, and Billing Procedures

10-31-13
HCR 220


    In patient benefits eligibility there are various things that can determine whether or not a patient is eligible for benefits. One thing is whether or not the patient has a premium if they are required to pay a premium it has to be paid first before the insurance starts paying their part. Medicaid eligibility is able to change on a monthly basis due to the fact members are required to turn in certain forms and report a change in income etc.   Another is if a person has an employer – sponsored health plan, the person’s status of employment becomes a deciding factor as well as the providers’ status as an in network or out –of- network provider as being listed on the plan master list of providers.
    The appropriate steps that would need to be taken if the patient insurance does not cover the plan and procedure to be done, then the healthcare provider need to inform the patient of the situation about their insurance eligibility of coverage. Therefore Ms. Smith should become aware that her delivery and prenatal care is not covered threw her insurance. So that way she could settle the financial account at that time.
    The two examples that I provided below relates to the eligibility factor of Ms. Sandra Smith charges with corresponding billing transactions.
Example 1
Service to be performed Prenatal Care, estimated charge $ 1,800 date of planned service March 8, 2011 reason for exclusion insurance does not cover.
I, Dylia Abbott is a patient of DR. Banias, understands that my insurance excludes prenatal care, which makes me liable for the service rendered.
Example 2
Service to be performed Labor /Delivery, estimated charge 9,700 date of planned service , January 3, 2012 reason for exclusion insurance does not cover labor and delivery.
I, Dylia Abbott is a patient of DR. Banias, understands that my insurance excludes, labor and delivery which makes me liable for the service rendered....