Patient is not Eligible on Date of service

Important factors of the denial

  • Treatment is done post the policy termination date.
  • The date of service doesn’t fall within the effective and the termination date.
  • The patient fails to update the active coverage information to the insurance.
  • the patient is not active for the date of service and insured to other insurance as primary.

Example

Mr. Patrick’s policy says the Effective date is 01/01/2018 and the termination date is on 01/02/2020. However, Patrick decided to do a full-body checkup and got an appointment with Ms.jasmine on 02/5/2020. After his body checkup went home. Few days after received his bill denied stating not eligible on the date of service.

Any answers? any guesses?comment below

Answer

The answer is Patricks’ date of service didn’t fall within the policy date range (01/01/2018-01/02/2020). Hence the denial is correct and Patrick owes the bill. However, if Patrick has secondary insurance active he can transfer the bill to secondary insurance.

Questionnaire flow chart for Patient is not Eligible on Date of service

patient is not eligible on date of service

Recommended action

To sum up, If the claim denied as the Patient is not Eligible on the Date of service. You can check the two things. Firstly, the Effective date and termination date of the patient’s policy. If the date of service falls within the date range request rep to reprocess the claim. Secondly, when it is not under the date range check for any secondary for the patient. Consequently, to avoid billing the patient directly or you can follow the protocol of the organization.

Read more ——>Participating provider VS Non participating provider

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