Jd Revised Undestanding Insurance Eliigibilityprocess Iii
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Notas do Editor
This presentation should help clarify some of your questions on insurance admissions and to respond to some basic question the patients may have prior to their admission.
Why it is important to work the insurance intakes as much as the private pay intakes.
Most commercial policy have either an in-network contract or out of network contract, with some policy having both in and out of network benefits.
PPO affiliation: LAP in-network with BCBS/Magellan PPO, Value Options, Cigna/GM, Compsych. NO HMO. PPO affiliation: MH Out of network with all insurance (policy must have OON coverage)
Eligibility: Policy must be effective prior to admission or treatment.Non active coverage: Policy termed or termination of employment or non payment for month to month policy.Cobra: Payment to extend coverage after policy term. Patient either pays directly to insurance company or bring the payment at admission along with the cobra paper work.Pre-exiting: Insurance companies impose an exclusion for care base on either a particular diagnosis or length of coverage.Benefits: Detail descriptions of what exactly the policy covers. What portion of care is the patient’s responsibility and what portion is the insurance responsibility.
Mental health and substance care are base on different level of care base on medical necessity which make up the 30 days stay. Most patient will stay for 30 days in treatment at different level during that stay. The insurance companies have strict guidelines for qualification at those level of care. A full face to face assessment at the upon admission is required to determine at what level of care the patient will be placed.
These are some basic information necessary for pre-admission and admission. The pre-admission step is a crucial part of the intake assessment in order to ensure a smooth admission in our facilities.