Eligibility denial which contributes 35-38% of overall denial in Medical billing. Understand the basics of this denial

1. Eligibility
Denial Series

2. Eligibility Basics
• Premium
• Effective date & Termination Date
• TPA
• Medicare – MCO
• Medicaid – MCO
• COB

3. Denial - Insurance
• Coverage is not in effect
• Date of service prior to coverage started
• Care may be covered by other payer
• Patient is not active
• Patient can’t be identified as our member
• Patient id # is invalid

4. Precall Analysis
• Check the related DOS in software- paid
• Check with other groups if applicable
• Check in Web site to confirm the eligibility
• Check in THI (if applicable)
• Filter by patient last name, address
• Check any notes available General
comments

5. Information @ Calling
• Date of denial
• Effective/ termination date.
• EOB request
• Check if any other insurance information is
update in their system.
• If the denial is incorrect – send this for
reprocess.
• Call ref # - claim #

6. Post call Action
• Enter the Termination date in Software
• Check if any insurance is available in
deleted FSC
• Check the eligibility for all the insurance
available in Registration
• If any insurance is active check whether it is
prim/sec.
• If Prim file the claim or Bill the patient - self
pay.

7. https://provider2.anthem.com/
wps/portal/ebpmybcbsco

8. MAIN SCREEN FOR
ELIGIBLITY VERIFICATION

9. NAME SEARCH ELIGIBILITY
VERIFICATION

10. OUT OF STATE MEMBER
SEARCH

12. Below is the link for Aetna, Cigna and UHC (United
healthcare) www.navinet.navimedix.com

13. If any patient is above 65 Years old.
Please check eligibility at Medicare
• Medicare number previously with SSN with letters and
this will be changed from Jan 1st 2020. Medicare will use
MBI (Medicare Beneficiary Identifiers)
 Up to 11 digits, Non Intelligent Number
 Position 1 – numeric values 1 thru 9
 Position 2 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
 Position 3 – alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z)
 Position 4 – numeric values 0 thru 9
 Position 5 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
 Position 6 – alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z)
Position 7 – numeric values 0 thru 9
 Position 8 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
 Position 9 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
 Position 10 – numeric values 0 thru 9
 Position 11 – numeric values 0 thru 9

14. Eligibility – Medicaid
RR patients
• Eligibility…..

15. How this denial is Important
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
DENIAL
CQS
BROOKLYN
SSMC
CURADIOLOGY

16. Types of Eligibility denials
• Other insurance is primary
• Claim filed to Wrong Insurance as per
plan
• Patient is ineligible on DOS
• PCP is not Member PCP/
Restricted Recipient Patients-
Medicaid

17. Who is Restricted Recipient
• Potentially Overusing or Misusing
Medicaid services
• Forged Prescription or Fiscal orders
• The possession of multiple Medicaid cards
• Card loaning or sharing
• The selling of drugs or other supplies from
Medicaid

18. How they are restricted
• Medicaid notify the individual in writing of its intent to
restrict service
• The recipient is asked to accept a proposed provider or
select another provider
• If the recipient fails to respond within 10 days, Medicaid will
restrict service to the proposed provider
• The recipient must go to the designated providers for
Medicaid services.
• Additional limitations may be placed on certain medications
such as controlled drugs and/or other habit forming Drugs.

19. Who can treat these patients?
• Only designated Provider/ Group can treat this
patients
• Appropriate Referral – Non designated providers
• If service is provided to a restricted enrollee by a
non-primary provider, the primary provider must
be contacted to inform them of the service being
rendered and to obtain the primary provider's
Medicaid provider identification number for billing
purposes

20. Referral form

21. How to Identify This Patients
• By checking in Epaces
• By Checking denied EOB
• Verifying Eligibility with Medicaid HMO

22. Checking Epaces- Same Group

23. Checking Epaces- different Provider
/Group

24. EOB

25. How to fix
• Medicaid
If our group is designated:
• Mark this patient as RR Patient in IDX
master when entering Patient Name.
• Epaces- Verify RR status
• RR patient- Add group NPI # & name in
the Referring Physician column by manual
entry
• If No RR status – Go as per Charge sheet.

26. Medicaid HMO
Provider Status
• Referring Provider – linked with Group NPI/Tax
id- sent for review.
• If Referring Provider not linked Change the
Referring provider as Group & with NPI refile
corrected claim.

27. If our Group is not designated
• Check who is PCP for this Patient
• Get the referral from the PCP
• Use PCP NPI # In referring provider
column
• Refile the claim

28. If the patient don’t have
referral from PCP
• At the time of service inform the patient
that he is responsible for this payment and
mark this as self pay Category patient.
• Once claim was denied bill the patient or
follow project specific instructions.