It is, at best, difficult to predict whether a patient will have met their deductible by the time a claim is processed. For this reason, most providers assume that payment will be forthcoming from the insurance payer. For this reason, healthcare providers routinely assign payment responsibility and submit claims as if any relevant deductible has already been met. If it turns out that the deductible has not been met, the insurer’s EOB will reflect that status, denying payment and handing responsibility for payment to the next insurance payer, or back to the patient if there is no other insurance to bill.
Recording the Insurance Denial
In order to record the denial and transfer payment responsiblity, you would use a Credit entry as follows, taking information from the insurer’s EOB:
- Open a new Credit entry from the Daysheet list.
- Select the appropriate patient account and Payer.
- Choose “DEN: Denial” as the Credit Type, and an appropriate Denial Code such as “DED: Deductible not met”. (If an appropriately descriptive code is not already in the pick list, simply add one using the New button at the bottom of the lookup list.)
- Leave the Credit Amount as “$0.00”.
- Highlight the Charge entry that was denied and click the Apply Credit button.
- The Credit Split window will open, showing the zero amount in the Apply A Credit Amount panel. To transfer responsiblity to the next payer, enter the amount to be transferred in the Optional – Transfer all or remaining charge split balance panel. SOS automatically determines and displays the next payer, which will be the next available insurance payer or, if no other insurance payers, the non-insurance payer, in that order.