Thursday, June 10, 2010

Pre - Existing denial - CO 51

CO - 51 These are non-covered services because this is a pre-existing condition. Denial and Action

Pre-existing condition refers to the terms and conditions entered in to between the carrier and the patients/subscribers before the beginning of the contract.  The rejection will usually say that the claim is being denied due to the pre-existing condition.  It would not specify what exactly; the condition is.  So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything.

A). there may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing the limit.  If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition.

B). there may be a condition that the carrier would not be paying for the same diagnosis more that once in a year. If a same diagnosis code is used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating pre-existing condition.

    Action:  as soon as you receive the denial,  check with insurance on the pre-existing condition. If the patient has secondary coverage with the secondary if we can send the entire bill to secondary along with the primary denial.  Some carriers may be willing to pay for the same.  If the patient has no secondary coverage/ secondary refused to pay the request you to bill the patient.

pre-existing condition

In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage

screening programs

Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem.

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