Billing > Billing

Which benefit period applies?

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Sophrosyne:
More specifically this is the case: the patient owes $15 co-pay. However, the patient had met her 2011 OOP in July of 2011. VO had for months (from July to December) been paying at 100% and all EOBs stated that the patient owed nothing. EXCEPT for her last visit in 2011--date of service 12/21/2011. Because VO received the claim on 01/09/2012, DOS 12/21/2011 was applied to the 2012 benefits (in which the patient has not yet met her OOP). Thus, the patient owes the $15 co-pay (according to this rep).


--- Quote from: PMRNC on February 28, 2012, 09:48:12 PM ---
--- Quote --- 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. 

--- End quote ---

I didn't quite understand this bit. Are you saying if the patient exhausted her 2011 visit limit, the carrier could use date of receipt of the claim to apply it to the 2012 visit limit? Cause that would be fine with me if this were the case!  ;D  However, in this case, the patient has unlimited visits (for both 2011 and 2012), so I don't think this is the issue here.

There's supposed to be a VO supervisor calling me sometime this week, so I'll let y'all know what she says! Thanks!
--- End quote ---

Michele:
I agree.  She either explained it wrong or she just plain HAD it wrong.  If the policy is a calender year policy from 1/1 - 12/31 they cannot choose to apply one years service to another year based on receipt date.  Like Linda said, maybe they have 'last quarter carryover' or something but from what you've described they met their oop in 2011 so that wouldn't apply.  I would call and get a different person and argue the point.

PMRNC:
I have to agree, I would call and speak with someone else.. i will say this from working at a few carriers... IF that claim was processed using automatic plan calculation, their software is almost error / bullet proof.. a manual calculation would indicate an error on the processing end..but of course you wouldn't know that unless you processed claims.  I'm ONLY guessing that based on that fact, the plan is NOT a calendar year plan and the rep explained something the wrong way.

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