Patinet Eligibility

Patient Eligibility

HCR/220

January 14, 2011

Patient Eligibility

This summary will explain factors that determine a patient eligibility for medical services as well as the appropriate steps to take when patient has no insurance and examples of patient charges with corresponding billing transactions.

Number of factors determines person eligibility for medical services; one way is from the patient information form and his or her insurance cards. The payer is then contacted insurance to conform eligibility and three points are verified, such as patient general eligibility for benefits, the amount of the co-payment, and if the plan encounter is for a covered services, which is medically necessary. All these steps are required before care is provided to the patient, expect in a medical emergency; a patient is provided care and then the process of eligibility will be checked after patient is treated.

A patient that has a government sponsored plan, such as Medicaid, the main eligibility is a person income and his or her eligibility can change from month to month. An employer sponsored health plan uses a person employment status as the determining factor for eligibility. Sometimes a patient may no longer qualify as a group member and sometimes a patient plan may not cover services, like annual visits. Some health benefits are not provided to part-time employees.

When insurance does not cover planned services; administration would then discuss with the patient that the services requested are not covered and let him or her know that he or she is responsible for the charges. Sometimes facilities have specific forms a patient must fill out; these forms makes certain that he or she understands the services requested are not covered by his or her insurance. This is an important process to determine so that a patient can be informed ahead of time what his or her financial responsibilities are for services.

Fred Jones is a returning patient, he is complaining of chest...