Izimangalo Eziphezulu Zezingu-10 Zishiya

Ukuqonda izizathu zokuthi kungani izimangalo zezokwelapha ziphikisiwe ngabashuwalense zingasiza ukukhawulela inani lokuphika ihhovisi lakho lezokwelapha elitholayo. Indlela yodwa yokuzivimbela ukuthi baqaphele lokho abayikho.

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Ukwazisa Isikhombi Sokugula Esingaqondile

Kubalulekile ukuthi ufake i-claim yezokwelapha ngolwazi olunembile lokuhlonza isiguli. Ngaphandle kwalolu lwazi olubalulekile, uhlelo lomshuwalense wezempilo alukwazi ukubona isiguli ukukhokha noma ukusebenzisa ulwazi lwesimangalo lisetshenziselwa i-akhawunti yomshuwalense wezempilo yesiguli esifanele.

Amanye amaphutha avamile kakhulu angabangela isimangalo sokuphika ngenxa yokwaziswa okungalungile kwezihlonzi zesiguli kukhona:

• Igama lobhalisile noma isiguli liphrofwa ngokungalungile
• Usuku lokubeletha noma lokugula kwesibalo ku-isimangalo aluhambisani nosuku lokuzalwa ohlelweni lwepulano lwempilo yomshuwalense
• Inombolo yobhalisile ayitholakali esimangalo noma engavumelekile
• Inombolo yeqembu labhalisile ayitholakali noma ayivumelekile

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Ukupheliswa Kuphelile

Ukuqinisekisa izinzuzo zomshuwalense ngaphambi kwezinsizakalo ezinikezwayo kungaxwayisa ihhovisi lezokwelapha uma ngabe umshwalense wegciwane usebenza noma uqede. Lokhu kuzokuvumela ukuthi uthole ulwazi oluthe xaxa lwamanje lomshuwalense noma ukuthola isiguli njengakhokhela.

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Kudinga ukugunyazwa kuqala noma ukuqinisekiswa kwangaphambili

Izinsizakalo eziningi ezibhekwa njengezimo eziphuthumayo zingadinga ukugunyazwa ngaphambi. Kuyinto evamile ukuba abakhokhisi abaningi bomshuwalense badinga ukugunyazwa ngaphambi kwemisebenzi ebiza kakhulu ye-radiology njenge-ultrasound, i-CT, ne-MRI. Izinqubo ezithile zokuhlinzekwa neziguli ezingenayo iziguli zingadinga ukugunyazwa ngaphambi.

Izinsizakalo ezinikezwa isiguli ezidinga ukugunyazwa ngaphambilini zinganqatshelwa ngumkhokhi womshuwalense. Amasevisi angeke avunyelwe uma izinsizakalo ezinikeziwe zibhekwa njengesimo esiphuthumayo sezokwelapha. Umhlinzeki angase azame ukuthola i-retro-ukugunyazwa kungakapheli amahora angu-24 kuya kwangu-72 ngemuva kokuthi izinsizakalo zitholwe kuye ngokulandela imihlahlandlela yabakhokhisi bomshuwalense.

Okuningi

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Izinsizakalo ezingavunyelwe noma ezingekho

Ukungaxhunyiwe noma izinsizakalo ezingahlanganisiwe kubhekisela ezinsizakalweni ezithile zehhovisi lezokwelapha ezingabandakanywa nokutholakala komshuwalense wezempilo. Iziguli kuzodingeka ukhokhe amaphesenti angu-100 kulawa masevisi.

Lesi esinye isizathu sokubaluleka kokuxhumana nomshuwalense wesiguli ngaphambi kwezinsizakalo ezinikezwayo. Kungumsebenzi wamakhasimende ompofu ukukhokhela isiguli ngamacala angeke ahlanganiswe ngaphandle kokubenza baqaphele ukuthi bangabhekene namacala ngaphambi kwenqubo yabo.

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Isicelo samarekhodi wezokwelapha

Ezinye izinhlelo zomshuwalense wezempilo zingase zicele amarekhodi ezokwelapha uma isimangalo sidinga amanye amadokhumenti ukuze kuqinisekiswe isimangalo. Irekhodi yezokwelapha lifaka kodwa alikhawulelwe kulokhu okulandelayo:

• Umlando wezokwelapha ogulayo
• Imibiko yomzimba enesineke
• Imibiko yokubonisana nodokotela
• Izifinyezo zokukhipha iziguli
• Imibiko ye-Radiology
• Imibiko yokusebenza

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Ukuhlelwa Kwezinzuzo

Ukuhlanganiswa kokuphikiswa kokuhlomula kungabandakanya:

• Omunye umshuwalense uyinhloko
• I-EOB engekho ( ukulinganisa izinzuzo )
• Ilungu alizange livuselele umshuwalense ngolunye ulwazi lomshuwalense

Ukuhlanganiswa kwezinzuzo kuyisigameko esetshenziswa lapho isiguli sinamapulani amabili yomshuwalense wezempilo noma ngaphezulu. Imithetho ethile isebenza ukunquma ukuthi iyiphi inqubo yomshuwalense wezempilo ekhokhela okuyinhloko, yesibili noma ephakeme. Kunemihlahlandlela eminingana yokunquma ukuthi yikuphi ukulandelwa kwehhovisi lezokwelapha okufanele likhokhise uhlelo lomshuwalense wezempilo.

Okuningi

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Bill Billing Carrier

Uma ngabe isimangalo sibhalwe njengengozi ephathelene nokuzibophezela noma okuphathelene nomsebenzi, abanye abathwali bayokwenqaba ukukhokha kuze kube yilapho umshwalense wezimoto noma othintekayo wenkokhelo yesibambiso ekhokhisiwe.

Mayelana nezinsizakalo ezihlobene nengozi, umshuwalense wemfanelo elandelayo wesithathu kumele uhlale unikezwa njengenhloko:

1. Imoto noma Umshwalense Wokuzivocavoca okubandakanya akukhophutha, inqubomgomo noma i-Med Pay
2. Umshuwalense Wokuvuselelwa Komsebenzi
3. Umshuwalense womninikhaya
4. Umshwalensi Wokungasebenzi
5. Umshuwalense Wokukhokhelwa Kwebhizinisi

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Amakhodi we-CPT noma ama-HCPCS angavumelekile

Ukuze izimangalo zezokwelapha zisebenze ngendlela efanele, kunamakhodi ajwayelekile asetshenziselwa ukukhomba amasevisi nezinqubo. Le ndlela yokubhala ikhodi ibizwa ngokuthi i-Healthcare Common Procedure System Coding System (i-HCPCS futhi iveza "ukukhethwa kwama-hicks.")

Qinisekisa ukuthi amakhodi wakho wezokwelapha ahlale ahleliwe kumakhodi we-HCPCS. Izinguquko kumakhodi we-HCPCS zibuyekezwa ngezikhathi ezithile ngenxa yamakhodi amasha athuthukiswa ngezinqubo ezintsha namakhodi wamanje abuyekezwa noma alahlwa.

Okuningi

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Ukufakela ngesikhathi

Qaphela isikhathi sokugcina isikhathi sokuthumela umshwalense ngamunye. Ezinye izibonelo zezikhathi zokugcina zokufaka zifaka phakathi:

• Ukunakekelwa Kwezempilo Kwe-United: Imingcele yokufaka ngesikhathi esifanele ichazwe kwisivumelwano somhlinzeki
• I-Cigna: Ngaphandle kokuba umthetho wezwe noma omunye uhlukile usebenza -
  1. Abahlinzeki bokunakekelwa kwezempilo abathintekayo banezinyanga ezintathu (3) (izinsuku ezingu-90) ngemuva kosuku lomsebenzi.
  2. Abahlinzeki be-out-of-network banezinyanga eziyisithupha (6) (izinsuku ezingu-180) ngemuva kosuku lwenkonzo.
• I-Aetna: Ngaphandle kokuba umthetho wezwe noma omunye uhlangothi lusebenza -
  1. Odokotela banezinsuku ezingu-90 kusukela ngosuku lomsebenzi ukuhambisa isimangalo sokukhokha.
  2. Izibhedlela zinonyaka owodwa kusukela ngosuku lwenkonzo ukuhambisa isimangalo sokukhokha.
• I-TRICARE: Izimangalo kufanele zithunyelwe kungakapheli unyaka owodwa emva kosuku lwenkonzo.

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Akukho Ukudluliselwa Kufayela

Ezinye izinqubo zidinga ukuthi isiguli sithola ukuhanjiswa kudokotela wabo womndeni ngaphambi kokunikezelwa kwezinsizakalo.