Eligibility, Payment and Billing Procedures

A factor that determines patient benefits eligibility would come from the patients’ information form and their insurance card - Eligibility, Payment and Billing Procedures introduction. The medical insurance specialists would then contact the payer to confirm eligibility, any copayment that the patients are required to pay before care is rendered and whether the care they are seeking is a covered service under their plan. These steps are required before care is provided to the patient except in a medical emergency. If there is an emergency the patient is taken care of and the process of eligibility will be checked after the patient has been seen.

With Medicaid the eligibility can change from month to month. When the insurance does not cover a planned service for the patient, the medical specialist will discuss with the patient that the service they are requesting is not covered and that they are responsible for the charges. Some physicians have specific forms for patients to fill out make certain that they understand the services they are requesting are not covered by their insurance and they are obligated to pay. A patient may be required to see someone outside their primary care doctor, when this happens they need a referral or a preauthorization.

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A referral or preauthorization may be given over the phone, fax, e-mail or other electronic transactions. But if the patient does not have a referral or preauthorization they will have to pay for the services. When a referral or preauthorization is given, the patients will have to bring in documentation to the specialists. If the patients do not have the referral or preauthorization at the time, they will have to provide it within a specific time frame otherwise the patient will have to pay for the service they received.

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