"Thats not how it works. Thats not how any of this works."
I work for government healthcare not private insurance. I work professional-to-professional so it’s usually not too horrible. But people do think they know everything.
A claim was denied because it was determined to be non-emergency. (An example would be someone going to the ER to get staples removed.) You can have general eligibility but still have claims denied for reasons like that.
Me: gives denial and explanation Customer: has the patient been seen in the last 12 months by their PCP? (A requirement to keep eligibility.)
Me: I’ll be happy to verify that for you. I do want to advise that has no bearing on the current denial …. [looks up info] yes, they have been seen on the last 12 months.
Customer: so can you send the claim back since your processed it wrong?
Me: it was not processed wrong. The patient has eligibility in general but the claim did not reach the prudent layperson definition of an emergency.
Customer: but they were seen within 12 months.
Me: this is a correct denial. You have to appeal.