NON-PARTICIPATING PROVIDER

A provider that does not sign a contract to participate in a
health plan and refuses to accept insurance allowable as
payment in full.

In commercial plans, non-participating providers are also
called “Out-of-Network Providers” or “Out of Plan
Providers”.

If a beneficiary receives service from an out of network
provider, the health plan will pay for the service at a
reduced rate or will not pay at all. In Medicare Program,
this refers to providers who are therefore not obliged to
accept assignment on all Medicare claims.

Non-Participating Provider also referred to as “Non-Par”
elects not to participate with given health care plan. In
some instances, provider bills patient for the difference
between the allowed amount and fee for the service
provided.
Some health plans have limitations on how much patient
can be billed for. The health plan will send payment to the
patient and the patient will be responsible for paying the
provider.

PARTICIPATING PROVIDER

A provider that has contracted with an insurance carrier or Managed Care plan to provide health services to plan members. A physician or group of physicians can participate as single entity with insurance company. A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan. They are deemed to be “in-network”.
Agree to participate with an insurance program means Physician agrees:

To accept assignment for all claims he submits:
means the physician requests direct payment
from the insurance,
To accept insurance allowable as payment in full
for services regardless of the charge he makes,
To complete and file the claim forms for the
patient at no charge for the patient, and
Not to bill the patient for services determined by
the carrier to be not reasonable and necessary.

PRE-EXISTING CONDITION

A pre-existing condition is a condition or injury requiring
treatment and/or management prior to the subscriber’s
effective date with the current insurer. Generally specific
time guidelines are stated qualifying at what point (if any)
the carrier will pay for services pertaining to this
condition or injury.
“Waiting Period” is the period of time from coverage
effective dates that insurer does not cover pre-existing
medical condition. The individual will normally be covered
for the condition once the specified time has elapsed. Also
called “Pre-existing Condition Exclusionary Period”.

Federal law defines a pre-existing condition as any
condition for which medical advice was given or
treatment was recommended by or received from a
physician within six months before the effective date of
coverage. Medigap insurers are required to reduce the
pre-existing condition waiting period by the number of
days an individual was covered under some form of
"creditable" coverage so long as there were no breaks in
coverage of more than 63 calendar days.

"A pre-existing condition is a medical condition that would
cause a normally prudent person to seek treatment during
the twelve months prior to the beginning of coverage."

Coverage Waivers: If you have a condition, illness, or
injury that can be identified as one that does not
necessarily affect your overall good health but could
affect risk balance of all insured's, Unicare may waive
that condition from coverage. This means that expenses
for treatment of that condition or any other condition
related to it will not be covered for a specified period of
time.

Medicare Rejection Codes

004 The procedure code is inconsistent with the modifier used or a required modifier is missing.
005 The procedure code or bill type is inconsistent with the place of service.
006 The procedure code is inconsistent with the patient's age.
007 The procedure code is inconsistent with the patient's gender.
008 The procedure code is inconsistent with the provider type.
009 The diagnosis is inconsistent with the patient's age.
010 The diagnosis is inconsistent with the patient's gender.
011 The diagnosis is inconsistent with the procedure.
012 The diagnosis is inconsistent with the provider type.
013 The date of death precedes the date of service.
014 The date of birth follows the date of service.
015 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
016 Claim or service lacks information, which is needed for adjudication.
018 Duplicate claim or service
022 Payment adjusted because this care may be covered by another payer per coordination of benefits.
023 Payment adjusted because charges have been paid by another payer.

028 Coverage not in effect at the time the service was provided.
029 The time limit for filing has expired.
031 Claim denied as patient cannot be identified as our insured.
035 Benefit maximum has been reached.
036 Balance does not exceed co-payment amount.
037 Balance does not exceed deductible.
038 Services not provided or authorized by designated (network) providers.
039 Services denied at the time authorization or pre-certification was requested.
040 Charges do not meet qualifications for emergent or urgent care.
042 Charges exceed our fee schedule or maximum allowable amount.
045 Charges exceed your contracted or legislated fee arrangement.
047 This (these) diagnosis (es) is (are) not covered, missing, or are invalid.
048 This (these) procedure(s) is (are) not covered.
052 The referring or prescribing or rendering provider is not eligible to refer or prescribe or order or perform the service billed.
056 Claim or service denied because procedure or treatment has not been deemed 'proven to be effective' by the payer.
057 Payment denied or reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
062 Payment denied or reduced for absence of, or exceeded, pre-certification or authorization.
078 Non-Covered days or Room charge adjustment
096 Non-Covered charge(s)
097 Payment is included in the allowance for another service or procedure.
110 Billing date precedes service date.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period has been reached.
120 Patient is covered by a managed care plan.
125 Payment adjusted due to a submission or billing error(s).
133 The disposition of this claim or service is pending further review.
135 Claim denied, Interim bills cannot be processed.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
148 Claim or service rejected at this time because information from another provider was not provided or was insufficient or incomplete.

Claims Timely Filling Limits

AARP - 15 Months
Advantage Care -6 months
Aetna – 4months
American Progressive -1 year
Bankers Life -15 Months
Bcbs Florida – 1 year
Bcbs Michigan – 1 year
Health plus – 1 year
Blue shield High Mark -2 months
Cigna – 6months
Citrus -1 year
First Health -3months
GHI -1 year
Greatwest-15 Months
Horizon NJ Plus -1 year
Humana -27 months
Keystone Health Plant east-2 months
Magna Care - 6 months
MARILYN ELECTRO IND. BENEFIT FUND- 1 year
Medicaid – 6 months
Medicare – 2 calendar years
United health care – 3 months
NASI - 2 years
Quality Health Plan - 1 year
Tri care - 12 months
UHC – 3 months
Veterans Admin – 3 months
Auto No fault – One year