SHAA: A Case Study

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Tammie, There appears to be confusion on how to process a routine physical for children and adults on SHAA. The Extensivie-SHA14 Certificate of Coverage indicates that there is a benefit of $1,000.00 for Preventative Care; however, the exclusion states that a Routine Physical Exam is not covered. The wording does not have a Preventative definition, which would have possibly deciphered what the intent of the benefit. Additionally, the Accumulators are built in LCS for the Preventative Benefit but the Codes That Rule do not reflect this benefit. Note, we did receive a claim for a five year old (Insured ID: 82124717) wellness visit and it was denied, which prompted the insured’s father to contact us requesting a reason for the denial when

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