Hi there , If a claim got denied due to a patient is in active on date of service 7/5/17 . However, the office got a fax back on 7/4/17 showed that patient is active. Rep from insurance company said that because they didn’t receive the information from the employer after the DOS. What is the best way to appeal the situation?

Hi there , If a claim got denied due to a patient is in active on date of service 7/5/17 . However, the office got a fax back on 7/4/17 showed that patient is active. Rep from insurance company said that because they didn’t receive the information from the employer after the DOS. What is the best way to appeal the situation?

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Asked on August 3, 2017 12:59 pm
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The problem here is fax back eligibility does not guarantee payment from the carrier it merely states to the best of their knowledge the patient is active and eligible for treatment under the plan.

You may try to appeal this decision by refiling the claim and sending in fax back proof of eligibility at time service was rendered. However to try and have these kinds of denials overturned and paid in most cases does not happen. You may want to pull out your contract with the carrier and see what your options are, in most instances there will be a specific type of appeal that is allowed under your contract with the carrier.

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Answered on August 4, 2017 12:59 pm
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