Deductible (PR1)

It is a fixed amount that the policyholder needs to pay out of pocket to provider before an insurance company starts paying for the health expense to the provider.
For example, if John has annual deductible of $1000.00 and he undergoes a treatment that costs $700.00. So, it will be applied toward deductible, and john need to pay this amount.
If John undergoes for second treatment again that costs $1,000 then this time insurance will apply $300.00 towards the patient deductible and the remaining $300 will be borne by insurance company or as per plan john has opt for.

If plan has higher deductible that means patient need to pay lower premium.
If plan has lower deductible that means patient need to pay higher premium. It is recommended for the patient who has a chronic medical condition as it requires a regular visit to health care professionals.
The deductible clause can be of two types either in terms of visit or dollar amount. So it totally depends on the patient insurance plans.

Account Receivable scenario:

Whenever there is denial of PR 1, Always review the history tab over PMS software about other claims for the calendar year to find out if claim was paid or processed toward deductible or paid
If claim was processed toward deductible, then need to follow up with insurance about additional information of how much is the total deductible amount of the year and how much is remaining.
If insurance has paid other claim previously of that calendar year, then call insurance representative to challenge the decision by stating that annual deductible is already met request representative to reprocess the claim correctly.
If deductible is true, then need to transfer the balance to patient.

True Denials: PR1-DEDUCTIBLE, PR2-COINSURANCE, PR3-COPAY

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Deductible