Wiki Capitated patient

[edmedbilling]

Hello,
We are in network with Medicare. Not in network with Medicaid or any of the Medicaid Capitated plans.

If we see a patient that gives us the wrong insurance, this one said they have medicare, and medicare denies the claim as capitated hmo patient. Patient is covered under Molinia HMO which we are not in contract with.

Can we bill the patient?

 

[haraml7]

Hello,
We are in network with Medicare. Not in network with Medicaid or any of the Medicaid Capitated plans.

If we see a patient that gives us the wrong insurance, this one said they have medicare, and medicare denies the claim as capitated hmo patient. Patient is covered under Molinia HMO which we are not in contract with.

Can we bill the patient?

Does the patient have out of network benefits?

Can you send it to Molina to get a denial from Molina and/or a processed claim.

Alot of patients assume the HMO plans are Medicare plans not realizing the HMO replaces their traditional al medicare.

 

[edmedbilling]

Molina already denied it then tried to tell us to write it off even though we are not in network with any capitated plans.

 

[haraml7]

Ok, what is the reason for the denial, Is is a CO96, or PR96. The type of denial would determine if you could bill the patient or not. the CO stands for contract and the contract denial would mean that you CANNOT bill the patient.

Also, is there a remark code on the EOB, like M or N remark codes following the denial?