Monday, June 21, 2010

Claim denied as "NON-COVERED SERVICES" - Can we bill patient

Claim denied as "NON-COVERED SERVICES"


Billing for services not covered under the Medicare program.

Action :

Keep in mind that there's a lengthy list of Medicare exclusions such as: Personal comfort items; self-administered drugs and biologicals (i.e., pills and other medications not administered by injection); cosmetic surgery (unless done to repair an accidental injury or improvement of a malformed body member); eye exams for the purpose of prescribing, fitting or changing eyeglasses or contact lenses in the absence of disease or injury to the eye; routine immunizations; routine physicals; lab tests and X-rays performed for screening purposes; hearing aids; routine dental (care, treatment, filling, removal or replacement of teeth); custodial care, services furnished or paid by government institutions; services resulting from acts of war; and charges to Medicare for services furnished by a physician to immediate relatives or members of the same household.

Stay up-to-date on current exclusion policies by checking with your Medicare carrier and/or their Web site for changes. Most carriers will post changes to policies and their effective date. If not, go directly to Medicare's Web site at and find them there.

0309 Services Not Covered

Verify the client’s eligibility on our Medicall system. If the client is eligible, contact the Provider Helpline to verify that the client is enrolled in the program for which services were billed.

Billing for non-covered services and billing patient

As a reminder, contracted physicians and other professional providers may collect payment from subscribers for copayments, co-insurance and deductible amounts. The physician or other professional provider may not charge the subscriber more than the patient share shown on their provider claim summary (PCS) or electronic remittance advice (ERA).

In the event that BCBSTX determines that a proposed service is not a covered service, the physician or other professional provider must inform the subscriber in writing in advance. This will allow the physician or other professional provider to bill the subscriber for the non-covered service rendered.

In no event shall a contracted physician or other professional provider collect payment from the subscriber for identified hospital acquired conditions and/or never events.

1 comment:

  1. I have gone through a denial as non covered under provider contract. As per insurance provider is out of net work so they don't cover the claim. My question is if the provider and patient already know that provider is not in network with the plan why did they send the claim to insurance to process?


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