What is the term for any procedure or service reported on the claim that is not included on the master benefit list?

The term that signifies any procedure or service reported on a claim that is not included on the master benefit list is referred to as a noncovered benefit. This means that the specific service or procedure is not eligible for reimbursement by the insurance company under the terms of the patient’s health plan.

Insurance plans have a master benefit list, which outlines the services that are covered. Procedures not included on this list fall into the category of noncovered benefits. Consequently, healthcare providers will not receive payment for these services, impacting the revenue cycle.

Disallowed charges refer to specific service charges that have been reduced or deemed not payable, typically after an insurance review. Excluded services, while similar, often refer to services that some plans explicitly list as not eligible for coverage, but may not always denote the absence on a benefit list. Pending review suggests that a claim is still under consideration and has not yet been finalized, thus does not accurately represent the status of a service that is not covered. Recognizing this terminology is critical in Revenue Cycle Management to ensure accurate billing and understanding of service reimbursements.