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Linda
Brandwin, R.N.
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Linda
Brandwin
is a registered nurse and a medical billing
and claims specialist. For the past 10 years
she has worked directly with insurance companies
to give advice and guidance to the health care
consumer.
Readers may send email
or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.
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No
diagnosis code for health problem
Nov. 7, 2003
Q:
I went to a physician who is a specialist for my medical
problem. I had an office visit and some blood tests.
He was able to diagnose me and treat my medical condition.
He said that my insurance company won't pay for this
visit because presently, there is no diagnosis code
for what is wrong with me. He has written articles on
my condition and has said that he is one of ten specialists
in the country who can treat my problem. So now I feel
much better but have a $500 bill that he said my insurance
won't pay. Do you have any suggestions?
A:
An insurance company needs a procedure code and a diagnosis
code to process a claim. A procedure code identifies
what the doctor did to you and a diagnosis code tells
why he did it. A diagnosis code has to justify the procedure
code. For example, if I had a throat culture performed,
the diagnosis on the insurance claim might read sore
throat. That is a good reason for having my throat swabbed.
The diagnosis wouldn't be eye infection or the claim
would not be paid.
In
your case, at this time, the disease that you are being
treated for has not been recognized by insurance companies
and has not been given a diagnosis code. Therefore,
the medical claim can not be processed. However, there
may be some things you can try. Most likely these suggestions
won't make any difference and the claim will still be
denied. But you will receive some feedback from your
explanation of benefits. The rejection codes may provide
you a starting point and you may be able to pursue some
other avenues that can result in payment.
Definitely
submit this medical claim to your insurance company.
The procedures and charges will be on the bill. The
diagnosis will be missing. Call your doctor's office
and ask for copies of his medical notes and lab results
from your chart. Include these documents with your claim.
Also ask the doctor's office for copies of any articles
he has written and any brochures or pamphlets he has.
Include these also with your claim.
Now
wait for the explanation of benefits to arrive. If the
claim was paid, fine. If it was rejected, call a supervisor
and go over your case with her. Once she has all of
the material from your claim, she may send it on to
a review panel. The supervisor may be able to offer
you more advice and suggestions. Sometimes there are
many different avenues to pursue to get a claim paid.
In some circumstances such as this one, you may not
want to accept the initial denial of a claim. You never
know how much maneuvering room you have for another
approach to get this claim paid.
Your
best source of information for dental insurance policies
is your dentist's account and billing department. They
deal directly with all of the policies of their patients.
They should be able to answer all of your questions
and offer guidance in selecting the best plan for your
needs. Once you receive that information, you can do
some comparison shopping on your own.
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