Common Claim Issues

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Common Claim Issues

There are some issues that come up occasionally when sending claims to insurance companies. Please review the list below for some common problems with claims submission.

 

Topics

What Are Some Reasons the Insurance Provider Might Pay $0.00?

Why Might an Insurance Provider Reject a Claim?

What Are Some Reasons the Insurance Provider Might Not be Paying Enough?

 

 

What Are Some Reasons the Insurance Provider Might Pay $0.00?

 

The patient may not have met their deductible yet.

This often happens at the beginning of the year. Sometimes insurance companies will waive the deductible if the patient uses a generic drug.

 

The patient may have another insurance company that will cover the copay.

 

 

Why Might an Insurance Provider Reject a Claim?

 

Syntax Error: This type of error means the claim was not formatted correctly.

This issue will likely involve interaction with the insurance company and Fusion.

 

Refill Too Early: This type of error means that it is too soon for the patient to receive the medication.

Standard procedure in this situation is to put the fill on hold and set the Administration Date as the date given in the claim.

 

 

What Are Some Reasons the Insurance Provider Might Not be Paying Enough?

 

The pharmacy may be sending a "Usual and Customary" amount that is too low.

ProPharm One+ calculates the Usual and Customary amount based on the pharmacy's Default Price Table. Check the default price table and the drug being dispensed.

 

The pharmacy may not be sending a dispensing fee.

A Dispensing Fee is one way to raise the price of the claim. Check the dispensing fee that is being sent in the Claim Verify window.