Case Study: Response To Sara Lime

When the alleged incident occurred, I, Sarah Karwowski, reserved a room in the HTCC for an Economics study session. I invited Daniel Clark to join us in the room to study/work on homework. While my group and I were working on Econ, Daniel was working on the take home exam for DSCI 259 by himself. Daniel sat at the far end of the table opposite of our study group, where he had ample space to spread out his class notes and practice problems on the table. Amik Kler and friend Michael, who were uninvited to the reserved room, entered the study room upon seeing Daniel. Amik sat down directly across from Daniel and proceeded to take out his copy of the take home exam for DSCI 259, with complete knowledge that Daniel was working on the same exam.

The provider had an authorization on file approving the dental services advising that they were medically necessary. But when the provider billed, they only advised the services were dental and not medical. Therefore causing the claim to deny. Also, provider didn’t reference their authorization number in box 63 of their claim form which would have voided the claim from denying. This claim will be sent back to be reprocessed. Please advise and ETA of 01/13.

The arrangement did not work, as the son-in-law used Ms. Inez insurance for his diabetic supplies. She showed me her medications that were in his name.

The lifecycle of physician-based claim (CMS 1500) is something that we not only need to know, but also how to do from start to finish.

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

After a review of the concerns presented in Ms. Edwards’ inquiry to your office, we have determined that Keelin Edwards has met her $500.00 calendar year deductible.

tier, they can ask the patient’s plan for an allowance for a lower co-payment. Mrs. Zwicks’s part

The patient is informed about their coverage and the amount of copayment they would have to pay.

she does not use a supplier that accepts Medicare assignments she will have to pay the entire

Health plans cover care for members who have different levels of expected cost and utilization due to differences in demographics and diseases.

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

Some dentists’ offices might see you as just another insurance plan or credit card, so they push you to get work you don’t need or feel comfortable getting. We know how upsetting that can be, which is why we are dedicated to working with you for your dental care. We offer a variety of services, but we always take the time to explain the pros and cons of each treatment. This way, you can rest assured that you have picked the right option for your dental health and budget.

Since 1984, Medicare patients have been serviced under the prospective payment system of the Medicare program. Under this system, primary care providers are reimbursed for their services using a fixed payment for each patient that is determined by the patient’s diagnosis-related group at the time of the admission. Therefore, under the prospective payment system a hospital’s reimbursement is unaffected by the actual expenditures that are required to care for a patient.

I am writing in response to Nicoleta Shamah’s inquiry to the Illinois Department of Insurance dated September 1, 2016. In the inquiry, Mrs. Shamah requested a network waiver for her son, Nasser Shamah, to see Dr. Marisa Klein-Gitelman.

This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the Beneficiary Notices Initiative to alert the Medicare beneficiary prior to rendering the service. The Medicare beneficiary is notified via the Advance Beneficiary Notice (ABN) (see page 235 in Appendix B).