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Eligibility, Payment, and Billing Procedures Essay

Describe a factor that determines patient benefits eligibility. Many factors determine a patient’s eligibility for benefits. Employment status is one factor that may determine whether or not the patient still has benefits. If an employee no longer has a job they are by law to be offered what is known as COBRA by their employer for up to one year of termination or a new job whichever comes first. What are the appropriate steps to take when insurance does not cover a planned service? If a planned service was not covered by the insurance there are appropriate steps that the doctor’s office should take. First they need to make the patient aware of the situation and discuss further if they still want the procedure done or if they are capable of making the payments to cover the procedure. After talking with the patient the doctor needs to have the patient sign financial agreement forms to make sure that they was informed of the situation and the proof the doctor needs so the patients does not say they was not informed about the situation.

Relate these steps to the eligibility factor you identified and provide two examples of patient charges with corresponding billing transactions. The patient should be informed of the recommendations of preventive care as well as immunizations. They must also be informed that they insurance will not cover these expenses and if performed it is ultimately the patients responsibility to cover these charges before the procedure is completed. When a patient chooses to have dental work done and then braces put on. The coverage may be first denied because it is considered cosmetic. However, there are appeal forms that you can fill out and tell your side of the story. Example: Poor teeth and crowding of teeth can lead to heart disease. This is what you can put in the appeal form along with the dentist’s information. The appeal may be denied or approved. If denied then you can either chose not to have the procedure done or to make a payment plan.

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