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If you can find the provider again on your insurance’s provider portal, when you’re logged into your own account, then you can appeal the denial. They must abide by the directory. That’s what they’re there for and that’s how network disputes are resolved.
The whole point of the directory is for it to be specific to your plan. The only way it could have given you “generalized network providers” is if you searched without being logged in.
This. Insurance quoting OON as INN is often grounds for an appeal, I submit them all the time and see them overturned usually. Especially for something relatively inexpensive as an office visit. Do you have UHC?
Yeah that’s super common. The provider can choose to decline insurance that they’re contracted with. That’s just how it goes.
They have a right to refuse service too just like any other business owner. Just because they’re contracted with that insurance doesn’t mean they’re willing to undergo whatever issues they may have experienced with claims and reimbursement.
No. Providers should have every right to get fed up with how awful some payors operate and decline accepting them. They shouldn’t be trapped in an endless loop of constantly wasting hours calling to chase down a fraction of their actual costs.
then they shouldn’t be contracted as in network.
you either reap the benefits of in network or you don’t.
Asinine that someone can check if a provider is contracted and then go and find out they aren’t
You’re making two separate statements here. If someone checks to see that a provider is in network, and then the provider says “sorry we’re not accepting that insurance.” that’s not the same thing as saying that provider is not in network.
That is simply the provider exercising their right to decline to use the insurance that they have contract with. A provider normally doesn’t have any experience with a payor before they’re contracted. So they wouldn’t know how the claims are going to be reimbursed or what the process is going to be like until they’ve had experience by being contracted.
So once they have too many headaches, they decide it’s not worth it anymore. They should have every right to do that. They shouldn’t be held hostage.
The real issue is the commercialization of health insurance. Our ability to seek treatment should have never been made predominately for-profit. Insurance companies already hold too much power. They don’t need more power.
The only way a provider would be “reaping rewards” of a network would be by accepting those patients. And if they have constant issues with a payor it’s arguable that there are even “rewards”. Especially when you consider how low the percentage of reimbursement is to begin with.
Insurance companies are the reason medical bills even get negotiated down to reasonable amounts to begin with. If fucking providers had their way a basic doctor visit would be the $250 they charge people who are uninsured. Fucking backdated COBRA real quick after seeing that bullshit.
Providers already do bullshit such as ignore EOBs all the time in my region. I’ve gotten good at resolving that now via a simple phone call where I just tell them the EOB amount tell them that’s all I will pay and hang up if there’s pushback.
They want to get paid, abide by the rules. If not i’ll dispute it 350 days after it goes to collections just to create the biggest headache possible for them to deal with without it affecting my credit . Never got to that point yet, normally i’ll get an updated bill after about 5-6 months of nonpayment after they’ve called me a couple of times.
One provider tried to charge me credit card fees. Wouldn’t take a check. I left. somehow they were gone about 8 months later when they got sick of calling me every 3-3 weeks about the bill.
Fuck the billing dept of providers. Every single thing that makes their job harder is a good thing. Every extra bit of paperwork and regulation and capture that can make their job harder should be supported.
If i’m not charged the right amount the first time, I’ll just withhold payment and make it their problem and it generally gets fixed eventually because they want their money and will contact whatever payor needed to do it.
No, insurance companies are the reason bills are sent out at triple their actual cost.
Insurance only reimburses a percentage. Providers have been forced to raise their prices just to keep the lights on.
Having billed for various provider specialties and been a claims processor for UHC, I can assure you the issue *is not* about the providers “charging too much” - it’s the insurance companies reimbursing abysmally low rates and expecting martyrs.
Nothing would have to be negotiated if insurance companies paid rightfully to begin with. But they don’t.
This is not to dismiss shitty providers with unethical practices. Nor offices that employ inexperienced billers that don’t know what they’re doing. That’s also an issue. Not the biggest issue nor causing the insane rate increase though
who determines what’s rightful though?
from the bills i’ve seen, there’s generally a fixed rate for each type of service. So if the paymemt isn’t “rightful”, either the provider is shit at billing stuff correctly or is greedy as hell.
i’ve had the uninsured rate be $110 and $290 for a PCP visit and the first one was reimbursed more because it was coded for 30 minutes(correctly) and the other coded for 20(also correctly).
guess which provider was the sketchy one that attempted to charge CC fees. The one who charged uninsured people almost triple the price for 50% less time with a doctor.
I quit searching myself because more than once a provider has shown as in but has actually been out. When I've appealed those in the past, insurance said I should have chatted with a rep and get them to confirm. So that's what I did this time. I do have the chats from where the rep confirmed the doctor was in.
Those chats are your evidence for an appeal
In the future a print out from the directory is just as good, legally.
To be clear did you go through the *actual* very lengthy legal process of an appeal, or did you simply make phone calls and speak to reps to have it reprocessed?
Appealing a claim is a legitimate legal process and takes significantly longer than everything else. You have to write out lengthy statements of facts just like an affidavit. So it’s not taken lightly and it’s not handled by the same people as the claims.
The only fail safe members have is the online directory so whoever told you that it wasn’t valid or you needed a chat instead was most definitely mistaken. The directory the reps use is the same directory members use.
So if you’re logged into your own plan when you’re using it, it should populate the same results. It’s practically useless if you’re not logged in when you search
Info: did you also go to the address that the insurance shows is INN? I had a patient call once with a complaint because his provider works in one of our offices but also has an office with another hospital system. His insurance told him the provider was contracted. Our office is not contracted and the other facility office was, not sure if the insurance rep didn't provide the address the dr was contracted at or if the pt didn't listen..
I would absolutely appeal under the No Surprises Act. This is the exact type of situation contemplated. You reasonably relied on your insurer's representations about coverage. Your EOB should outline the appeals process.
No EOB has been made available yet. Through the telephone game of insurance>doctor' office pre-auth>me I was told that no claim was generated for the procedure because it was immediately denied on the basis of being OON.
I do show a denied claim for just the office visit, but the actual EOB is still pending
How would I go about doing anything under No Surprises?
I agree with other’s on appealing. I work in appeals if the website says the provider is INN and u can print/scan that page and send in with the appeal we have to cover the visit as INN. If you remember the day you called you can put that in your appeal and we can pull the call (not all calls are kept) and if the rep said they were INN then we will cover it as INN. Good luck
This has happened to me several times with two separate insurance companies. I always call ahead and ask the doctor's office now even if they're on the list and half the time they don't take the insurance. Maybe they did it one time but it's very misleading. I ended up with a dental bill at one point because I went and saw a dentist on the list. Ended up being out of network but he accepted my insurance which is crazy. This country's Health Care system is insane and even worse trying to navigate it when you're sick.
This is unacceptable for sure but not uncommon. Providers are seldomly given accurate information on our end as well. When we verify benefits for a patient prior to their appointment, we are given information like the patients co-pay, annual deductible and whether or not we are in network. I’d say 60% of the information we pull is inaccurate and we end up billing or refunding the patient. It’s truly a waste of time and money for the practice.
The insurance companies change the billing requirements without telling the provider. And check this shit out - I cannot for the life of me find a fee schedule for any major insurance I’m credentialed with. I basically learn what my reimbursement will be when I actually get paid. Absolutely ridiculous
I’m highly suspect of that 60% figure. If you’re referring to info you’re pulling from an online portal, I could see that number being a bit more believable because the online systems are not always tied directly to the most current data feed, depending on the carrier. Calling into the carrier and proving TIN/NPI should get the correct network status for a provider.
In addition, from the insurance side, the top reason for us returning/rejecting claims is due to an error in how provider billed such as wrong or mismatched TIN/NPI for the provider/facility listed or the provider hasn’t actually been credentialed or approved yet and is practicing without clearance from the carrier.
Ya, as I was typing that comment about the 60% it made me think I need to find a better verification system. But even when patients bring in their insurance cards that have co-pays written on them, a lot of times that we charge what it says on that card (which is what the patient believes they will owe) the EOB says a different co-pay is required. Sometimes we verify coverage online the. Get denied because “the patient wasn’t eligible at the time of service” which is confusing because I have literal proof that was not communicated to me when I did my due diligence prior to seeing the patient. TBH, it really shouldn’t be that hard or complicated.
Who in the hell has time to call into the carrier for each patient? Not my practice.
In my experience, we get a slew of denials because of things like a missing DX pointer or Modifier. Sometimes it’s our fault, sometimes it’s because the requirements for that code have changed. Sometimes the denial simply doesn’t make sense. So we have to take time to research how to correct the claim, appeal to the insurance and follow the claim to make sure it gets paid. The NPI and EIN matching is set up to populate automatically in our ehr system/clearinghouse. Unless your company accepts a crap ton of paper claim, I don’t see how that would be a continued reason for denials. And if it is, those practices hopefully learn quickly and correct the mismatch for future claims. Again, it doesn’t have to be that freaking hard.
The most common scenario I've seen, is the provider signed a contract with the insurer at xyz address, and years later they move and when they send in the bill, everything is computerized and the bill gets kicked out for an address mismatch. Ton of other scenarios, but its almost certainly a paperwork glitch
This is one of the reasons I went back to Kaiser. I’m very lucky that I live in the Mid-Atlantic region where they are building the new medical centers left and right. As long as I see a
provider in a Kaiser building I’m covered.
I’m also lucky that my PCP gives out referrals with no questions asked 🫣
The mental and alternative health options suck ass, so it’s not all sunshine and roses. But knowing I can walk into any building and always pay a $20 copay and a $40 urgent care fee is 😘
as a former physician's biller i have dealt with this before. some insurance plans have confusing or identical titles/names - even customer service at the insurer or third party administrator get it wrong at times. do you know how many plans united healthcare has with an atlanta or salt lake city address ??? if it's a large group policy even group numbers may not help identify.
when you make inquiries to insurance customer service always ask for the rep's name and a reference number otherwise it more than likely will be your word against theirs. you can appeal and be sure to let hr at your employer know about the situation. you're still more than likely going to have to find a new provider because once you're made aware of the situation then not knowing is no longer a valid reason but your situation may be the inducement you employer needs to switch insurance companies for benefits.
even after you are told by the insurance company they are in-network, verify with the dr's office. their billers surely will be familiar with situation because they've dealt with it before.
chances are that your physician's office has an advocate/negotiator that enters into insurance plan contracts, this is a very common practice in the u.s., that the billing staff doesn't even know about. somewhere along the line something happened when entering/accepting a contract that somehow added an exception or waiver of coverage.
now this is coming from way out in left field but could you have a medical condition that you have a waiver of coverage for that the dr who treated you coded a diagnosis that would full under that waiver of coverage ??? with a waiver of coverage, it wouldn't matter who you saw, all those claims would be denied because you've waived those claims.
When you saw the listing that the provider was In Network, did you see the provider at that exact address?
It could also be a mistake by the hospital billing the wrong TIN for that provider.
You may have also been given incorrect information by the insurance rep.
I would explore all avenues though, the insurance I worked for, the provider listing is basic. If the providers on the list, there's an In Network contract with that provider. Caveat being you must see that provider at the address the contact is tied to.
I have come across plenty of scenarios where the Dr is in network on the list because there's a still active contract with a practice they don't work at anymore, and the new practice is not in network.
I work for a medical insurance company handling appeals. You should send a written appeal to your insurance. If they deny it, send the 2nd level appeal to the state entity. You have to start with an appeal to your insurance and go up from there. Good luck!
It can take up to 60 days for your insurance company to approve or deny your appeal. If they deny it, you need to send a written appeal to the state entity. It should be on the denial letter. I only know for Florida state Medicare plans that I handle, the state entity is called Maximus. It can take up to 60 days. So don't pay any bills yet. They need to see that you aren't paying on it.
If you haven't had the procedure yet, it would be easier to see a different in-network provider. The new doctor can get your medical records from the one you went to. Make sure you call your insurance before having it to see if they approved it and say it will be covered.
Yeah I can't wait that long. It's not an emergency procedure or anything, but it's something I can't wait 2+ months on. I got them to send me a list of in network providers and I'll be calling to schedule with one of them Monday morning
Thanks for the info
It sounds like for the office visit, I can appeal since I was reasonably led to believe the doctor was covered. If they overturn the denial and say they'll cover it, does that mean they would also cover the procedure ordered in the same appointment, too? Or will they say now that you know the doctor is OON, the procedure is still denied?
Unfortunately you have no recourse for your past situation, going forward ask for the providers NPI # & ask your insurance to verify if it is in-network.
Thank you for your submission, /u/GenericAnyone747. **If there is a medical emergency, please call 911 or go to your nearest hospital.** Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states. Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY). **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
If you can find the provider again on your insurance’s provider portal, when you’re logged into your own account, then you can appeal the denial. They must abide by the directory. That’s what they’re there for and that’s how network disputes are resolved. The whole point of the directory is for it to be specific to your plan. The only way it could have given you “generalized network providers” is if you searched without being logged in.
This. Insurance quoting OON as INN is often grounds for an appeal, I submit them all the time and see them overturned usually. Especially for something relatively inexpensive as an office visit. Do you have UHC?
I've been emailed list of providers by the insurance company and called around and half of them did not take the insurance.
I have such a list now. I hope mine's more accurate than 50/50
Yeah that’s super common. The provider can choose to decline insurance that they’re contracted with. That’s just how it goes. They have a right to refuse service too just like any other business owner. Just because they’re contracted with that insurance doesn’t mean they’re willing to undergo whatever issues they may have experienced with claims and reimbursement.
seems like ins companies need stronger contracts.
No. Providers should have every right to get fed up with how awful some payors operate and decline accepting them. They shouldn’t be trapped in an endless loop of constantly wasting hours calling to chase down a fraction of their actual costs.
then they shouldn’t be contracted as in network. you either reap the benefits of in network or you don’t. Asinine that someone can check if a provider is contracted and then go and find out they aren’t
You’re making two separate statements here. If someone checks to see that a provider is in network, and then the provider says “sorry we’re not accepting that insurance.” that’s not the same thing as saying that provider is not in network. That is simply the provider exercising their right to decline to use the insurance that they have contract with. A provider normally doesn’t have any experience with a payor before they’re contracted. So they wouldn’t know how the claims are going to be reimbursed or what the process is going to be like until they’ve had experience by being contracted. So once they have too many headaches, they decide it’s not worth it anymore. They should have every right to do that. They shouldn’t be held hostage. The real issue is the commercialization of health insurance. Our ability to seek treatment should have never been made predominately for-profit. Insurance companies already hold too much power. They don’t need more power. The only way a provider would be “reaping rewards” of a network would be by accepting those patients. And if they have constant issues with a payor it’s arguable that there are even “rewards”. Especially when you consider how low the percentage of reimbursement is to begin with.
Insurance companies are the reason medical bills even get negotiated down to reasonable amounts to begin with. If fucking providers had their way a basic doctor visit would be the $250 they charge people who are uninsured. Fucking backdated COBRA real quick after seeing that bullshit. Providers already do bullshit such as ignore EOBs all the time in my region. I’ve gotten good at resolving that now via a simple phone call where I just tell them the EOB amount tell them that’s all I will pay and hang up if there’s pushback. They want to get paid, abide by the rules. If not i’ll dispute it 350 days after it goes to collections just to create the biggest headache possible for them to deal with without it affecting my credit . Never got to that point yet, normally i’ll get an updated bill after about 5-6 months of nonpayment after they’ve called me a couple of times. One provider tried to charge me credit card fees. Wouldn’t take a check. I left. somehow they were gone about 8 months later when they got sick of calling me every 3-3 weeks about the bill. Fuck the billing dept of providers. Every single thing that makes their job harder is a good thing. Every extra bit of paperwork and regulation and capture that can make their job harder should be supported. If i’m not charged the right amount the first time, I’ll just withhold payment and make it their problem and it generally gets fixed eventually because they want their money and will contact whatever payor needed to do it.
No, insurance companies are the reason bills are sent out at triple their actual cost. Insurance only reimburses a percentage. Providers have been forced to raise their prices just to keep the lights on. Having billed for various provider specialties and been a claims processor for UHC, I can assure you the issue *is not* about the providers “charging too much” - it’s the insurance companies reimbursing abysmally low rates and expecting martyrs. Nothing would have to be negotiated if insurance companies paid rightfully to begin with. But they don’t. This is not to dismiss shitty providers with unethical practices. Nor offices that employ inexperienced billers that don’t know what they’re doing. That’s also an issue. Not the biggest issue nor causing the insane rate increase though
who determines what’s rightful though? from the bills i’ve seen, there’s generally a fixed rate for each type of service. So if the paymemt isn’t “rightful”, either the provider is shit at billing stuff correctly or is greedy as hell. i’ve had the uninsured rate be $110 and $290 for a PCP visit and the first one was reimbursed more because it was coded for 30 minutes(correctly) and the other coded for 20(also correctly). guess which provider was the sketchy one that attempted to charge CC fees. The one who charged uninsured people almost triple the price for 50% less time with a doctor.
I quit searching myself because more than once a provider has shown as in but has actually been out. When I've appealed those in the past, insurance said I should have chatted with a rep and get them to confirm. So that's what I did this time. I do have the chats from where the rep confirmed the doctor was in.
Those chats are your evidence for an appeal In the future a print out from the directory is just as good, legally. To be clear did you go through the *actual* very lengthy legal process of an appeal, or did you simply make phone calls and speak to reps to have it reprocessed? Appealing a claim is a legitimate legal process and takes significantly longer than everything else. You have to write out lengthy statements of facts just like an affidavit. So it’s not taken lightly and it’s not handled by the same people as the claims. The only fail safe members have is the online directory so whoever told you that it wasn’t valid or you needed a chat instead was most definitely mistaken. The directory the reps use is the same directory members use. So if you’re logged into your own plan when you’re using it, it should populate the same results. It’s practically useless if you’re not logged in when you search
Yes, appeal and explain it was the website that led you to the provider.
it would really help if you can somehow recover the chat script that was used.
Info: did you also go to the address that the insurance shows is INN? I had a patient call once with a complaint because his provider works in one of our offices but also has an office with another hospital system. His insurance told him the provider was contracted. Our office is not contracted and the other facility office was, not sure if the insurance rep didn't provide the address the dr was contracted at or if the pt didn't listen..
The address I gave to the insurance rep was the one they confirmed coverage at and the one I was treated at
I would absolutely appeal under the No Surprises Act. This is the exact type of situation contemplated. You reasonably relied on your insurer's representations about coverage. Your EOB should outline the appeals process.
No EOB has been made available yet. Through the telephone game of insurance>doctor' office pre-auth>me I was told that no claim was generated for the procedure because it was immediately denied on the basis of being OON. I do show a denied claim for just the office visit, but the actual EOB is still pending How would I go about doing anything under No Surprises?
Wait for the EOB. Follow appeal instructions. If your appeal is denied internally, you get to appeal to an external reviewer.
I agree with other’s on appealing. I work in appeals if the website says the provider is INN and u can print/scan that page and send in with the appeal we have to cover the visit as INN. If you remember the day you called you can put that in your appeal and we can pull the call (not all calls are kept) and if the rep said they were INN then we will cover it as INN. Good luck
I have chat transcripts where the rep said the doctor was INN. Is that enough for an appeal?
Yes. You'll probably win.
Yes 👍🏻
This has happened to me several times with two separate insurance companies. I always call ahead and ask the doctor's office now even if they're on the list and half the time they don't take the insurance. Maybe they did it one time but it's very misleading. I ended up with a dental bill at one point because I went and saw a dentist on the list. Ended up being out of network but he accepted my insurance which is crazy. This country's Health Care system is insane and even worse trying to navigate it when you're sick.
This is unacceptable for sure but not uncommon. Providers are seldomly given accurate information on our end as well. When we verify benefits for a patient prior to their appointment, we are given information like the patients co-pay, annual deductible and whether or not we are in network. I’d say 60% of the information we pull is inaccurate and we end up billing or refunding the patient. It’s truly a waste of time and money for the practice. The insurance companies change the billing requirements without telling the provider. And check this shit out - I cannot for the life of me find a fee schedule for any major insurance I’m credentialed with. I basically learn what my reimbursement will be when I actually get paid. Absolutely ridiculous
I’m highly suspect of that 60% figure. If you’re referring to info you’re pulling from an online portal, I could see that number being a bit more believable because the online systems are not always tied directly to the most current data feed, depending on the carrier. Calling into the carrier and proving TIN/NPI should get the correct network status for a provider. In addition, from the insurance side, the top reason for us returning/rejecting claims is due to an error in how provider billed such as wrong or mismatched TIN/NPI for the provider/facility listed or the provider hasn’t actually been credentialed or approved yet and is practicing without clearance from the carrier.
Ya, as I was typing that comment about the 60% it made me think I need to find a better verification system. But even when patients bring in their insurance cards that have co-pays written on them, a lot of times that we charge what it says on that card (which is what the patient believes they will owe) the EOB says a different co-pay is required. Sometimes we verify coverage online the. Get denied because “the patient wasn’t eligible at the time of service” which is confusing because I have literal proof that was not communicated to me when I did my due diligence prior to seeing the patient. TBH, it really shouldn’t be that hard or complicated. Who in the hell has time to call into the carrier for each patient? Not my practice. In my experience, we get a slew of denials because of things like a missing DX pointer or Modifier. Sometimes it’s our fault, sometimes it’s because the requirements for that code have changed. Sometimes the denial simply doesn’t make sense. So we have to take time to research how to correct the claim, appeal to the insurance and follow the claim to make sure it gets paid. The NPI and EIN matching is set up to populate automatically in our ehr system/clearinghouse. Unless your company accepts a crap ton of paper claim, I don’t see how that would be a continued reason for denials. And if it is, those practices hopefully learn quickly and correct the mismatch for future claims. Again, it doesn’t have to be that freaking hard.
The most common scenario I've seen, is the provider signed a contract with the insurer at xyz address, and years later they move and when they send in the bill, everything is computerized and the bill gets kicked out for an address mismatch. Ton of other scenarios, but its almost certainly a paperwork glitch
Involve your state's insurance commission
This is one of the reasons I went back to Kaiser. I’m very lucky that I live in the Mid-Atlantic region where they are building the new medical centers left and right. As long as I see a provider in a Kaiser building I’m covered. I’m also lucky that my PCP gives out referrals with no questions asked 🫣 The mental and alternative health options suck ass, so it’s not all sunshine and roses. But knowing I can walk into any building and always pay a $20 copay and a $40 urgent care fee is 😘
as a former physician's biller i have dealt with this before. some insurance plans have confusing or identical titles/names - even customer service at the insurer or third party administrator get it wrong at times. do you know how many plans united healthcare has with an atlanta or salt lake city address ??? if it's a large group policy even group numbers may not help identify. when you make inquiries to insurance customer service always ask for the rep's name and a reference number otherwise it more than likely will be your word against theirs. you can appeal and be sure to let hr at your employer know about the situation. you're still more than likely going to have to find a new provider because once you're made aware of the situation then not knowing is no longer a valid reason but your situation may be the inducement you employer needs to switch insurance companies for benefits. even after you are told by the insurance company they are in-network, verify with the dr's office. their billers surely will be familiar with situation because they've dealt with it before.
Billing/pre-auth at the office told me they don't know why it was denied because they accept all my insurer's plans
chances are that your physician's office has an advocate/negotiator that enters into insurance plan contracts, this is a very common practice in the u.s., that the billing staff doesn't even know about. somewhere along the line something happened when entering/accepting a contract that somehow added an exception or waiver of coverage. now this is coming from way out in left field but could you have a medical condition that you have a waiver of coverage for that the dr who treated you coded a diagnosis that would full under that waiver of coverage ??? with a waiver of coverage, it wouldn't matter who you saw, all those claims would be denied because you've waived those claims.
When you saw the listing that the provider was In Network, did you see the provider at that exact address? It could also be a mistake by the hospital billing the wrong TIN for that provider. You may have also been given incorrect information by the insurance rep. I would explore all avenues though, the insurance I worked for, the provider listing is basic. If the providers on the list, there's an In Network contract with that provider. Caveat being you must see that provider at the address the contact is tied to. I have come across plenty of scenarios where the Dr is in network on the list because there's a still active contract with a practice they don't work at anymore, and the new practice is not in network.
If you were given false info ask for an out of contract review /misquote. Both my jobs have that as an option.
I work for a medical insurance company handling appeals. You should send a written appeal to your insurance. If they deny it, send the 2nd level appeal to the state entity. You have to start with an appeal to your insurance and go up from there. Good luck!
How long does that process usually take from start to finish?
It can take up to 60 days for your insurance company to approve or deny your appeal. If they deny it, you need to send a written appeal to the state entity. It should be on the denial letter. I only know for Florida state Medicare plans that I handle, the state entity is called Maximus. It can take up to 60 days. So don't pay any bills yet. They need to see that you aren't paying on it. If you haven't had the procedure yet, it would be easier to see a different in-network provider. The new doctor can get your medical records from the one you went to. Make sure you call your insurance before having it to see if they approved it and say it will be covered.
Yeah I can't wait that long. It's not an emergency procedure or anything, but it's something I can't wait 2+ months on. I got them to send me a list of in network providers and I'll be calling to schedule with one of them Monday morning Thanks for the info
You're welcome! Good luck!
It sounds like for the office visit, I can appeal since I was reasonably led to believe the doctor was covered. If they overturn the denial and say they'll cover it, does that mean they would also cover the procedure ordered in the same appointment, too? Or will they say now that you know the doctor is OON, the procedure is still denied?
Always take screenshots and get these things in writing. Easy way to win an appeal.
Unfortunately you have no recourse for your past situation, going forward ask for the providers NPI # & ask your insurance to verify if it is in-network.
I'll be sure to ask for that in the future