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Claims Case Study

Here we have an AvMed Health Insurance claims example. AvMed is a non-profit Florida health insurance company. I point this out because we have had a good history of them paying their claims. That is why the issue in this case was so interesting and what prompted me to post it.


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Could you please advise why my client’s lab work was denied? I’ve attached the letter that AvMed sent him, together with the explanation of benefits, which indicates that services were excluded due to services being rendered for a pre-existing condition. However, after 7 months of coverage, the policyholder went in for a routine check-up and all came out well and this had nothing to do with a pre-existing condition – these labs were part of his routine check-up so I am not sure if the provider coded something incorrectly or what, but either way could you please help me in resolving this issue and having this claim reprocessed?

AvMed Claim Example

Our client spoke with an AvMed representative who advised that they would be sending him some pre-existing form to complete but they never sent it. I am presently on hold for 20 minutes with AvMed Member Services in hopes of trying to get this resolved.

Can you let me know if this is normal procedure and/or what I can do to get this claim reprocessed? It states on the letter that we have 180 days to file a grievance but there has to be another way of fixing this without filing an appeal, right?

After 30 minutes being on hold I finally got to speak with a representative at AvMed, which was actually great and informative!

12.30.09 2:40 PM As per Eileen, diagnosis on the claim is coded wrong. The primary diagnosis should be for a physical – that has to be the first diagnosis in order to be processed correctly. Please call the physician and request that they resubmit the claim with the primary diagnosis (code) as physical.

Apparently, the physician had the first diagnosis as another reason – i.e. if you go to a doctor for a physical but then mention that your foot has been hurting, the doctor should not note the primary diagnosis as an office visit for your foot, it should still be primarily for a physical.