If a patient’s employer has not submitted a premium, what claim status should the payer issue?

If a patient’s employer has not submitted a premium, what claim status should the payer issue?

• A. Denied
• B. Pending
• C. Approved
• D. On hold

Answer: (A)

Coverage is valid only when the employer has submitted the premium and the enrollment is active. If the premium has not been submitted, there is no active coverage to pay the claim, so the payer should deny the claim with a reason indicating lack of premium/payment or ineligibility due to nonpayment. A denied status reflects that the claim cannot be adjudicated for payment until the enrollment issue is resolved. Other statuses imply there is still processing or a temporary hold, but they do not represent a final determination of ineligibility due to missing premium. Therefore, denial is the correct outcome in this scenario.

Coverage is valid only when the employer has submitted the premium and the enrollment is active. If the premium has not been submitted, there is no active coverage to pay the claim, so the payer should deny the claim with a reason indicating lack of premium/payment or ineligibility due to nonpayment. A denied status reflects that the claim cannot be adjudicated for payment until the enrollment issue is resolved. Other statuses imply there is still processing or a temporary hold, but they do not represent a final determination of ineligibility due to missing premium. Therefore, denial is the correct outcome in this scenario.