If a service is not covered by the insurer and there are no errors on the claim, what is the next step?

If a service is not covered by the insurer and there are no errors on the claim, what is the next step?

• A. The claim will not be resubmitted and the patient will be billed
• B. The claim will be automatically resubmitted for reconsideration
• C. The insurer will request additional documentation
• D. The provider will issue a refund to the insurer

Answer: (A)

When a service isn’t covered by the insurer and the claim has no errors, the insurer won’t pay for that service. Since there’s nothing to fix or resubmit, there’s no automatic reconsideration process to trigger. The next step is for the provider to bill the patient for the remaining balance—the amount the patient is responsible for because the service is non-covered. This reflects the patient’s financial responsibility for non-covered services after the claim has been adjudicated.

When a service isn’t covered by the insurer and the claim has no errors, the insurer won’t pay for that service. Since there’s nothing to fix or resubmit, there’s no automatic reconsideration process to trigger. The next step is for the provider to bill the patient for the remaining balance—the amount the patient is responsible for because the service is non-covered. This reflects the patient’s financial responsibility for non-covered services after the claim has been adjudicated.