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Insurance guidelines for Pre-Existing.


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We had two claims for the same patient denied due to pre-exisiting conditions. Diabetes type II.

There are two things that bother me about this.
1) Patient changed insurance to join a group plan through her employer. I didn't think there were pre-existing when enrolled in group health plans.

2) When checking benefits online through the insurance provider portal, there is no provision for checking pre-existing conditions listed on the site.

My question is, who's responsibility is it to make sure Pre-exisiting conditions are known by the provider. Patients? Insurance? Providers??

Should we as providers treat and not get paid to find out about pre-existing conditions. And if the pre-exisiting conditions aren't listed on the benefits portal with the insurance company, should they not be liable to pay.

Does anyone know if there are regulations or industry standard regarding this.



Lauderdale Lakes
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Patients should know if they have a preexisting on their policy's. The only way a provider will find out is if they call and specifically ask the insurance about preexisting. When I get a claim denied for preexisting I bill the patient.


Best answers
It depends on the group size and the state mandates for group insurance. Small employer groups may have a 6 month pre-ex provision, some large employer groups may have one if they are an ASO-Administrative Services Only plan because then the employer is at risk, other large employers based on group size may not have that provision, depends on the carrier and state.

I agree with tpontillo, it is a member resp to understand their benefits. However if they have had any prior insurance coverage employer and/or individual based and there is <63 day break in between plans they could get credit towards the pre-ex or waived in full depending on the circumstance.

If you need to make sure if there is one, yep you need to call the carrier.

If at the point they are in a pre-ex review, you usually cant bill the member until the review is completed and it clearly says in a denial its pre-ex, then you can bill the member accordingly.