Question

guidelines. Medical Llp tile commission's contact information in the office medical billing manual as a reference in case a claim should be reported. CRITICAL THINKING APPLICATION 17-5 Ann is reviewing an encounter form for a CT scan of the knee. The patient is covered under an HMO plan, which requires preauthorization before the test is scheduled. Ann cannot find the preauthorization. She visits the online provider Web portal and finds out that no preauthorization was obtained. What can be done at this point? Will the claim be paid? EXPLANATION OF BENEFITS An Explanation of Benefits (EOB) is sent by the insurance company to the provider who submitted the insurance claim, which accom- or indicating that funds were electroni-

Answer 1

Formal approval from the insurance company that it will cover the test or procedure is very important and if the insurance company requires this and it is not done, then the patient risks having to pay the full amount for the procedure rather than having the opportunity to make other arrangements. In this case the procedure is done and insurance company's approval is not taken so the claim won't be paid and the patient has to pay the full fees.