CO 51 Pre-existing condition denial scenario and the solution

What is a CO 51 Pre-existing condition?

Medical illness/treatment or the injury that you have before you start a new health plan is called a CO 51 Pre-existing condition. For example, you have asthma since childhood and getting treatment till your 24th age and now suddenly shifting to a new plan. But, the new plan will not cover your pre-existing condition asthma.

Why insurance denying the pre-existing condition

Due to the high risk in financial assistance insurance may avoid covering the preexisting condition. There is no confirmation or prediction that one can give on patients’ medical conditions. The probability of success rate is very low. In some cases, the patient’s condition can lead to death(cancer).

What are the most common pre-existing conditions?

There is a lot of pre-existing conditions to explain some of them are general disease comes under as follows

  • Diabetes
  • asthma
  • clogged arteries
  • cancer
  • Pregnancy
  • Crohn’s disease
  • celiac disease
  • Alzheimer’s
  • cerebral palsy
  • epilepsy,
  • kidney disease
  • lupus
  • obsessive-compulsive disorder
  • multiple sclerosis

Premium loading for pre-existing conditions

You can add pre-existing diseases by opting for the Higher premium. Diseases like diabetes and heart problems can get this premium loading plan. For instance, if you are adding this plan existing treatment bills and expenses will carry out to this plan and you will get the reimbursement. Importantly, the premium plan costs too much for PEC.

The waiting period in CO 51 Pre-existing condition

In simple terms, the waiting period is called a time span during which you cannot claim the benefits of health insurance. In others words, you have to wait a certain period before claiming the insurance. The probability of getting reimbursement is very low.

Typically, most health insurance has a waiting period of 2-4 years. But it may differ from insurance to insurance referencing your age and what the condition is. In addition, they won’t cover your pre-existing conditions. They will cover only the ailments and injuries.

Example

Daniel participates in a cycling competition on behalf of his school. After a few days school arranged a medical camp for the students to test their fitness and health before competing. Daniel went on an observation, unfortunately, found sprained his ankle 10 days before. so school instructed him that he cannot participate this month. but can join the next month after recovery.

Ankle sprain Pre-existing Condition
Time allowed to recovery for the next participation Waiting period

Questionnaire Flow chart for CO 51 Pre-existing condition

CO51 pre-existing condition

Recommended action

In short, Two major scenarios you will face here. Firstly, Check the code billed is under pre-existing conditions. If it is PEC validate the waiting period. If the service within the waiting period bills the patient.if not ask the rep to send the claim back for review. Secondly, if the code billed is not under the Preexisting condition send the claim back for review.

 

3 thoughts on “CO 51 Pre-existing condition denial scenario and the solution”

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