Question

What determines patient eligibilty! Explain your answer.

what are the appropriate steps to take when insurance does not cover a planned service?

Answer 1

FACTORS DETERMINING PATIENT ELIGIBILITY:

• Age:Until 26 years old dependents should remain on their parents or guardians "family" plans.
• Gender:No discrimination of gender is allowed.
• Medical history:It includes medical conditions,surgeries and any prescription medications.Medical records from your physician need to be submitted about the medical history and conditions.
• Current health status:The current health conditions of the patient should be disclosed.

STEPS TO BE TAKEN WHEN INSURANCE DOES NOT COVER A PLANNED SERVICE

The Affordable Care Act states that health plans cannot exclude pre-existing conditions or apply pre-existing waiting condition waiting periods.

• Get a thorough knowledge of your insurance plan.
• Know the medical condition and the treatment options you have.
• Write an appeal letter and follow the process of filing the appeal as mentioned by your insurance company.The two ways to appeal are:

1. INTERNAL APPEAL:If your claim is denied,give an internal appeal to your insurance company to conduct a full and fair review of its decision.
2. EXTERNAL APPEAL:Your appeal can be taken to an independent third party for review.

• Speak up to your union to advocate on your behalf with the insurer.
• Keep all correspondence copies and notes of telephone and in-person conversations.