Eligibility, Payment, and Billing Procedures

Eligibility, Payment, and Billing procedures
HCR/220
September 20, 2012

There are a few factors to determine patient benefits eligibility. If there is a required premium, patients need to make those payments on time. If a patient receives medical coverage from the government eligibility can change monthly. Patients could also receive coverage from their employers and are only allowed to be seen by providers within the network, there may be instances where plans allow patients to be seen by providers??™ out-of-network. If a patient needs services that their plan does not cover, before the procedure is done the patient needs to be informed that their insurance does not cover the procedure needed and they will need to pay for the entire procedure out of pocket. Some payers require the physician to use specific documents to tell the patient about the services that are not covered and they need to be signed by the patient acknowledging that they understand their responsibility for payment. There are times when procedures need to be performed in an emergency that are not covered under the patients insurance that do not need approval.

Service to be performed: skin graph
Estimated charge: $400.00
Date of planned service: September 20, 2012
Reason for exclusion: skin graph is not covered under insurance.
I, ______, a patient of _______, understand the service described above is excluded from my health insurance. I am responsible for payment in full of the charges for this service.

Service to be performed: ultra sound
Estimated charge: $2009.00
Date of planned service: September 21, 2012
Reason for exclusion: ultrasound is not covered under insurance.
I, ______, a patient of _______, understand the service described above is excluded from my health insurance. I am responsible for payment in full of the charges for this service.

References
Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston, MA: McGraw-Hill.