What happens during a pre-existing condition inquiry?
A pre-existing conditions inquiry is a six-step process: • Your medical claim is identified as possibly being related to a pre-existing condition. First, the claim submitted by you or your doctor is reviewed to determine if it may be related to a pre-existing condition. • Your medical claim is initially denied while we gather more information. If it is determined that the medical service you received may be related to a pre-existing condition, your claim will be initially denied while we gather more information. Prior to July 12, 2010, the code “G7-Information Needed from Member” appeared on your Explanation of Benefits (the document you receive from us that explains how your medical services were covered) if a claim was denied for a pre-existing conditions inquiry. Now, a new code is being used: “GQ – More Information Needed Pre-X May Apply.” Your claim will be denied until the inquiry is complete, at which time all of your claims will be reprocessed appropriately. When you receive th
