EOB says I'm covered 100%

[ecmst12]

It shouldn't matter that you were diagnosed with something at the time of the visit. All that should be relevent is your reason for scheduling the appointment. If you scheduled it because it was time for your annual physical and you needed a checkup, then it's preventive care. If you scheduled it because you had specific problems/symptoms that you wanted to address, then it's diagnostic.

 

[lealea1005]

It shouldn't matter that you were diagnosed with something at the time of the visit. All that should be relevent is your reason for scheduling the appointment. If you scheduled it because it was time for your annual physical and you needed a checkup, then it's preventive care. If you scheduled it because you had specific problems/symptoms that you wanted to address, then it's diagnostic.

Not arguing with you ecmst...maybe I read it wrong, or read too much into what she was saying.

Certainly, if she was diagnosed as a result of screening bloodwork and/or exam at her "preventive" service, the coding would remain the same. However, if during the history and physical, she reported she was previously diangosed with something, regardless of whether she was treated, that diagnosis code must be included on the claim. The insurance company's computer may then kick the claim out because the diagnosis coding is not compatible with the (preventive, not problem focused) procedure coding. The service may still be "covered", but gets applied to her deductible.

If the Doc appeals it for her, they will have to send in her office notes for that day and the insurance company will make the determination of how they want to pay the claim.

 

[Vanessa54]

Not arguing with you ecmst...maybe I read it wrong, or read too much into what she was saying.

Certainly, if she was diagnosed as a result of screening bloodwork and/or exam at her "preventive" service, the coding would remain the same. However, if during the history and physical, she reported she was previously diangosed with something, regardless of whether she was treated, that diagnosis code must be included on the claim. The insurance company's computer may then kick the claim out because the diagnosis coding is not compatible with the (preventive, not problem focused) procedure coding. The service may still be "covered", but gets applied to her deductible.

If the Doc appeals it for her, they will have to send in her office notes for that day and the insurance company will make the determination of how they want to pay the claim.

I went to the doctor for a yearly thyroid bloodwork. He recommended I get a couple preventatives that at my age I should have done along time ago. I didn't go to see him for anything other than the bloodwork. He scheduled the preventatives, one at his office and the other with an in network doctor. After the paper work was submitted to insurance I got 2 EOBs showing I owed money. Both were resubmitted. One was taken care of, the other, which I have been having problems with was resubmitted, but without a reason so this is what caused the mix up. My info has been faxed to the insurance company. Hopfully to be taken care of before the end of the year.

 

[cbg]

FYI, even if the insurance is changing in January, the current insurer is still responsible for bills incurred during the current year. So even if it's not taken care of before the end of the year, it won't change whatever liability they end up with.