Monday, June 21, 2010

Insurance denial - Benefit exhausted.


Reason for Denial

Claim submitted after expired.
Benefit does not meet date criteria of the claim
No Benefit for service

    Action: when you get a denial with the above reason then check the system to see if the patient has any secondary insurance, if there is no sufficient information provided in the system then go back to the original file in which the patient’s insurance information was received and if there is a secondary insurance, the claim can be submitted to the secondary insurance, if it does then refile claims to that Ins.

This denial actually mean current insurance has already enough paid for this patient hence this insurance cant pay more. Patient coverage is active but insurance will not pay since the amount of maximum payable has been reached . Bill the patient for allowed amount.

Yes We could bill patient for this denial if patient does not have any other insurance.

Medicare Part A Benefit Exhaust Claims Requirements

Blue Cross requires the following when Medicare Part A benefits exhaust:

• Medicare exhaust letter, including the date Medicare benefits exhausted. Medicare Part A charges and Explanation of Benefits (EOB) must match.

• Blue Cross authorization from the date Medicare benefits exhausts.

• Medicare EOB for the entire stay.

• When Medicare has exhausted for the entire stay, one (1) claim needs to be submitted with admit date to discharge date inclusive of all Part A charges.

• When Medicare exhaust in the middle of the stay, two (2) claims should be submitted with one claim representing all services from the admit to the exhaust date and another claim listing the exhaust date to discharge date.

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