Author Topic: Typcial Process for InNetwork Provider but Specific Procedure not covered  (Read 1110 times)


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I'm working on a project with a Dermatologists office to standardize process and procedures and have a question for the experts on this message board related to billing and insurance payment.

In the case where the Dr is In-Network for a specific patient, but one of the procedures does not pay as insurance decided "not medically necessary". What is the amount the patient is then billed and responsible for?
1. Billed amount
2. Contracted amount for the procedure code (although not covered for this specific patient)
3. Some other amount

Thanks so much and I really like this forum, I'm new and have been on the website reading posts the last few hours!


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It depends on the provider's contract with the insurance carrier.  The contract may state that the provider cannot bill the patient for the disallowed service.  The eob should state what the patient responsibility is and that is what the patient can be billed.

Glad you are enjoying, that is what it is for!

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