If a patient's employer has not submitted a premium payment, which claim status should the provider receive from the payer?

If a patient's employer has not submitted a premium payment, which claim status should the provider receive from the payer?

• A. Denied
• B. Pending
• C. Paid
• D. Adjusted

Answer: (A)

In health insurance billing, whether a claim will be paid hinges on active coverage, which depends on premium payments. If the employer hasn’t submitted the premium, the policy isn’t in force, so there’s no valid coverage to pay the claim. The payer will deny the claim because the patient isn’t considered insured under an active plan. A Pending status would imply the payer is awaiting information to determine eligibility, which isn’t the case when the premium is unpaid and coverage isn’t active. Paid or adjusted would require an active, payable claim, which isn’t possible here. The provider should verify the patient’s eligibility and help resolve the premium issue so coverage can be restored before resubmitting.

In health insurance billing, whether a claim will be paid hinges on active coverage, which depends on premium payments. If the employer hasn’t submitted the premium, the policy isn’t in force, so there’s no valid coverage to pay the claim. The payer will deny the claim because the patient isn’t considered insured under an active plan. A Pending status would imply the payer is awaiting information to determine eligibility, which isn’t the case when the premium is unpaid and coverage isn’t active. Paid or adjusted would require an active, payable claim, which isn’t possible here. The provider should verify the patient’s eligibility and help resolve the premium issue so coverage can be restored before resubmitting.