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Which benefit period applies?

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Sophrosyne:
I've learned an interesting thing today--apparently Value Options decides which benefit period a claim applies to by the date the claim was received, not the date of service on the claim. To be more specific:
Patient has met 2011 OOP, all claims payable at 100% of allowed amount. We file a claim for date of service 12/21/2011. Value Options receives the claim on 01/09/2012 and proceeds to apply it to the 2012 benefits.
Can this be correct?!?! I thought it was always by date of service, not by the date the company received the claim. CONFUSED. Any thoughts?

DMK:
If the patient's policy is by CALENDAR year, the date of service should be applied to the benefit year of the date of service.  You may need to verify that their benefits don't renew in an odd month.  We have many teachers who renew on 7/1 of each year, not Jan. 1.  A phone call should get your question answered.

PMRNC:

--- Quote ---If the patient's policy is by CALENDAR year, the date of service should be applied to the benefit year of the date of service.  You may need to verify that their benefits don't renew in an odd month.  We have many teachers who renew on 7/1 of each year, not Jan. 1.  A phone call should get your question answered.
--- End quote ---

That's correct. My plan goes from Nov 1. 

Sophrosyne:
The Value Options rep I spoke with verified that the policy was a calendar year policy. She just said that VO applies the claim to a benefit period based on the day VO received the claim, not the date of service. So, according to this rep, date of service 12/21/11 counts towards the 2012 policy because they received in in 2012.
I have NEVER heard of anything like this before. Is this something VO can do? It seems very wrong to me, but that's hardly any leverage to go on.
Thanks all.

PMRNC:

--- Quote ---The Value Options rep I spoke with verified that the policy was a calendar year policy. She just said that VO applies the claim to a benefit period based on the day VO received the claim, not the date of service. So, according to this rep, date of service 12/21/11 counts towards the 2012 policy because they received in in 2012.
I have NEVER heard of anything like this before. Is this something VO can do? It seems very wrong to me, but that's hardly any leverage to go on.
Thanks all.
--- End quote ---

She either explained it wrong OR you misunderstood. MOST calendar year plan's have what's called carry-over months for deductibles/coinsurance, those carry over months are October, Nov, Dec.  If a patient had Not met their deductible by those months, the amount going to deductible would not only go to satisfy 2011's deductible but also 2012. So for example a patient has a visit of $200 on 12/1/2011. They had not met their deductible of let's say $100. $100 will be used to satisfy 2011 deductible AND it will also be applied to 2012's deductible.  So I'm thinking the rep may NOT have explained it correctly.  Now if they satisfied 2011 deductible but they are deducting deductible for 2012, that does not sound right.  If they are however counting the visit towards the benefit visit max for 2012 that's ok, yes carriers can use date of receipt of claim, at the end of the year if they exhaust the benefit, they may cancel out the prior year visit or two. 

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