Eligibility: Benefits

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 Describe a factor that determines patient benefits eligibility.  What are the appropriate steps to take when insurance does not cover a planned service?  Relate these steps to the eligibility factor you identified and provide two examples of patient charges with corresponding billing transactions.

There are a few factors that determine a patient’s benefits eligibility. Some of these include: whether a coverage may end on the last day of the month in which the employee’s active full-time service ends. The employee may no longer qualify as a member of the group. For instance if a part time employee does not get benefits at that job, the employee may lose benefits when they lose hours. An eligible dependent’s coverage may end on the last day of the month in which the dependent status also ends, or reaching the age limit stated in the policy. When you work for a company full time and receive benefits, if you drop down to part time, you may lose those benefits. Most places do this.

If someone is not eligible for the benefits trying to be used, the patient will then be responsible for the total themselves. Most offices require a signature stating that if your insurance does not cover the procedure or visit, the patient is then responsible for all charges. The place of business must let the patient know, first, that their insurance denied a claim and that they now have a balance due.

If someone with full-time benefits has preventative care with no copay, then drops down to part-time and less benefits, their policy could change and they could no longer have preventative services covered. Another example is, if you drop down to part time and you no longer receive benefits, you will have to pay in full for every service received.
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