Wiki Is there a limitation on length of time accident claims can be sent to insurance?

[h-rae]

In what time frame, if any, can you continue to submit claims to health insurance regarding a previous accident? For example, we sent out a charge with a DX of back pain and the patient called back stating their insurance didn't cover 100% because it wasn't listed as an injury DX with their accident dated back in 2010. There are two previous surgeries listed in their medical history to potentially correlate the pain directly related to the accident but the other three body parts that the patient indicates is pain due to injury don't 'follow' her medical history.

Is there a limit on how long you can continue to submit claims for pain, referencing a previous injury?

Any guidance is appreciated!

 

[cgaston]

I am a little confused about billing health insurance for an accident. Is the health insurance denying full payment stating it should be covered by WC/NF?

The only time constraints I can think of are regarding claim submissions. No Fault policies do have policy maximums, so those claims will eventually meet their policy maximum.

With Worker's Compensation claims what I have seen is that an Independent Medical Review is performed and the Physician performing the IME notes whether or not the pain is due to their injury, whether the patient has reached maximum medical improvement and, if not, what percentage of the chronic injury is due to their accident.

The WC carrier will pay any further claims according to the results of that IME. For example, if the IME states patient is 50% disabled from their accident, the WC carrier will pay 50% of their allowed amount for claim related to their injury and then the remaining would be the responsibility of the health insurance carrier. I am in NY so it may be different in other States.

So if their WC previous paid claims for, say, low back pain then I would bill them first. If they deny you can bill it to the health insurance carrier with a copy of the denial.