Eligibility_Payment_and_Billing_Procedures

CheckPoint : Eligibility, Payment, and Billing Procedures Maria A. Mendoza Natalie Cooper. HCR/220 November 11, 2010 Eligibility depends on the type of insurance that a patient have. For example a patient may have an insurance with the employer, and in this case, if premiums are required the patient has to pay for it. Another restriction that has to be check is the employment status with the company , for example: • If the patient active full time services ended for termination, or layoff or disability. • The employee change the status from full-time to part-time and it does not qualify for the services. • The patient is not longer eligible due to cases like age limit . Other patients have Medicaid, that are government plans, and they are based on the income ,and they can change monthly. Other plans such as HMO require a primary care provider (PCP), and in that case the family practice must verify that: • The provider is a plan participant • The patient is listed on the plan’s enrollment master list • The patient is assigned to the PCP as of the date of service. In this case the medical insurance specialist checks if the patient coverage is still active, by communicating online, or by e-mail with the provider. The medical insurance specialist communicates with the payer and receives the patient eligibility, the copayment amount, and all the necessary benefit information that is needed to cover the service. When the insurance does not cover the patients services, this situation needs to be informed to the patient, and explain the he or she is responsible for the charges. In that case there are forms that some payers required to the physicians to let the patient know about the uncovered services, and they need to be sign by the patient, confirming that the information was told and that the patient is obligated to pay before services are given. This steps are related to the patient eligibility of covered by how the medical insurance specialist takes the time and the effective communication with the payers to find out ,what are the patients coverage, and specific information to covered the visit. For example : if a patient has a medical insurance that does not covered pre-existing condition such as Autism, in many cases some special physicians will not be covered. In that case the patient needs to know what the payment responsibility will be for the visit. In some cases patients only receive a specific amount dollars per prescription glasses or certain percentage off . In that case the medical insurance specialist need to know in advance how much is the patient covered before showing glasses, that way the patient knows if he or she wants to pay out of pocket for the glasses. Reference ]Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.) Boston: McGraw-Hill.