What are Contractual Exclusions for a Medical Coder - dummies

What are Contractual Exclusions for a Medical Coder

For a medical coder, exclusivity may be a reference to procedures or it may relate to contractual terms. Payer contracts may pertain to the type of plan — Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), for example — sponsored by that company. Each plan has different payment obligations that must be met for a claim to be paid.

HMOs, for example, require the patient to name a primary care physician (PCP) who acts as a gatekeeper for spending the insurance company’s money. The patient is required to seek treatment from the PCP first. If that physician feels that the illness or injury requires the services of a specialist, then he may refer the patient to a specialist within the network.

Exclusivity may also refer to the network. Some plans do not allow patients to see out-of-network or non-contract providers. Their coverage is exclusive to providers within the network.

PPOs, for example, normally allow the patient to visit any provider that is contracted with the insurance company. If the patient visits a non-contracted provider, the claim is considered out-of-network, and the plan may pay for the services but at a much higher cost to the patient.

Contracts between payers and providers may contain fee schedules or payment agreements that are exclusive to various plans within their organization. These agreements are exclusive to the terms of the contract. They apply only to a certain payer under defined conditions, and claims must be filed within the terms defined in the contract(s).