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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Denial of health insurance claim because of not getting precertification
I had a procedure done and did not know I needed precertification and the doctor's office didn't do this with my insurance, so I got denied coverage for the procedure. My only option is to appeal, which I will. Has this happened to anyone and you won the appeal? All these loopholes with these insurance companies to not pay 
Message edited 3/20/2009 2:28:32 PM.
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Posted 3/20/09 2:08 PM  |
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Blazesyth
*yawn*
Member since 5/05 8129 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
I know, they're really difficult. Basically I call my company to confirm payment for everything besides a regular DR appt just because I want to be sure it will be covered.
Call them ASAP and try to work it out with them. They might cover it totally after some prodding - or at LEAST cover some portion of it.
Good Luck.
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| Posted 3/20/09 3:30 PM |
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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Posted by Blazesyth
I know, they're really difficult. Basically I call my company to confirm payment for everything besides a regular DR appt just because I want to be sure it will be covered.
Call them ASAP and try to work it out with them. They might cover it totally after some prodding - or at LEAST cover some portion of it.
Good Luck.
Thanks. I called the insurance company twice and spoke to two different people. They said the only way is to appeal. So I have to wait for paperwork in the mail to respond to it. Now I will get a bill from the doctor. What happens if I pay the doctor bill and then insurance decides to pay after appeal? Then doctor gets paid twice and I don't see any of it.
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| Posted 3/20/09 3:38 PM |
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Blazesyth
*yawn*
Member since 5/05 8129 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
If your insurance company does end up paying and you have already paid, the Dr should refund you the money you paid directly to him.
One thing you should definetly do is inform the dr of the situation and ask them to bill you at your insurance co's rate and not the general rate.
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| Posted 3/20/09 3:52 PM |
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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Posted by Blazesyth
If your insurance company does end up paying and you have already paid, the Dr should refund you the money you paid directly to him.
One thing you should definetly do is inform the dr of the situation and ask them to bill you at your insurance co's rate and not the general rate.
Thanks for all your input.
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| Posted 3/20/09 4:34 PM |
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dm24angel
Happiness
Member since 5/05 34581 total posts
Name:
Donna
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Re: Denial of health insurance claim because of not getting precertification
Always appeal....but as someone who worked for yrs in health insurance, I will tell you, they will fight it.
Thats why they make the benefit books...and people would say, well who has time to read those...well the people who dont wanna get stuck paying.
insurance is such a slippery slope and they will fight everything.
So advice to everyone is to call before you have anything done, or make sure you have a benefit book and look up everything. Its the only way to save yourself a whole lot of money.
Do you have an HMO? That might eb the way you can win, if its a HMO and your Primary dr coordinates your care, they are kinda somewhat responsible to tell you about pre certs.
Good luck!!!
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| Posted 3/21/09 10:55 AM |
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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Posted by dm24angel
Always appeal....but as someone who worked for yrs in health insurance, I will tell you, they will fight it.
Thats why they make the benefit books...and people would say, well who has time to read those...well the people who dont wanna get stuck paying.
insurance is such a slippery slope and they will fight everything.
So advice to everyone is to call before you have anything done, or make sure you have a benefit book and look up everything. Its the only way to save yourself a whole lot of money.
Do you have an HMO? That might eb the way you can win, if its a HMO and your Primary dr coordinates your care, they are kinda somewhat responsible to tell you about pre certs.
Good luck!!!
Thanks for the info. I have a PPO and funny thing is, there is no booklet for the PPO plan. I will put that in my appeal letter as part of it.
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| Posted 3/21/09 1:01 PM |
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Re: Denial of health insurance claim because of not getting precertification
If the doctor accepts your plan, they may have had an obligation to request the certification or maybe to inform you of the necessity. There are attorneys who handle these appeals. If it is a large amount of money, consider calling your county bar association for the name of someone. I agree that your insurance company will fight it but that does not mean you will lose.
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| Posted 3/21/09 7:13 PM |
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neener1211
:-)
Member since 4/07 22952 total posts
Name:
J
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Re: Denial of health insurance claim because of not getting precertification
Oh man, I can only tell you that I am still fighting a procedure from April of 2008. I have my HR person looking into it every time the doctor sends me a letter asking for payment.
We finally found that my insurance plan states that my DOCTOR has to ask for precertification, that it is not my responsibility. So, that loophole shoes that the doctor is at fault and I don't have to pay because I had no idea I needed prequalification since the doctor was in my plan.
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| Posted 3/21/09 9:13 PM |
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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Posted by neener1211
Oh man, I can only tell you that I am still fighting a procedure from April of 2008. I have my HR person looking into it every time the doctor sends me a letter asking for payment.
We finally found that my insurance plan states that my DOCTOR has to ask for precertification, that it is not my responsibility. So, that loophole shoes that the doctor is at fault and I don't have to pay because I had no idea I needed prequalification since the doctor was in my plan.
Sorry you are going through this too. I always thought it was the office's responsibility. Have you appealed with the insurance company? They tell you that you are not responsible to pay it, but what are you supposed to do, ignore bills from the doctor? This is ridiculous. I am waiting for some kind of letter in the mail so I can respond with a letter of my appeal. What insurance do you have? I have BC/BS.
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| Posted 3/22/09 7:46 AM |
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Christine
2nd verse same as the 1st
Member since 5/05 15287 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Keep appealing.
The owner of my company asked me to help him get a CT-Scan paid for. Get this - it was approved for say October 1st. He was at the doctor on 9/25 and it became more urgent to get the CT-Scan and there was an opening so he got the scan a couple of days early. DENIED. It took a couple of months to get it straighted out.
Good luck!! See if your HR dept will let you work with the broker/ins rep directly. They can reach people at the insurance companies we can't as a member of a group policy.
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| Posted 3/22/09 9:42 AM |
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MommyofG
just the girls
Member since 5/05 9461 total posts
Name:
Janice
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Re: Denial of health insurance claim because of not getting precertification
Yikes, this happened to me too. I had a procedure done that my obgyn sent me out to do I thought well they know my insurance and they are sending me here. well turns out my insurance company did not cover this procedure and if the office sent out for precertification they would have known.
I learned the hard way not to put my trust into an office and make sure I know referral, preceritication, covered procedure.
luckily the place I had this procedure done worked with me and only charged me what my insurance would have payed to them had it been a covered procedure. it was still a large amount but I did it in payments.
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| Posted 3/23/09 1:34 AM |
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CAH127
LIF Adult
Member since 7/07 1694 total posts
Name:
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Re: Denial of health insurance claim because of not getting precertification
Posted by MommyofG
Yikes, this happened to me too. I had a procedure done that my obgyn sent me out to do I thought well they know my insurance and they are sending me here. well turns out my insurance company did not cover this procedure and if the office sent out for precertification they would have known.
I learned the hard way not to put my trust into an office and make sure I know referral, preceritication, covered procedure.
luckily the place I had this procedure done worked with me and only charged me what my insurance would have payed to them had it been a covered procedure. it was still a large amount but I did it in payments.
So sorry this happened to you. Can I ask, did you try to appeal it? I am going to do it and see what happens.
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| Posted 3/23/09 11:23 AM |
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neener1211
:-)
Member since 4/07 22952 total posts
Name:
J
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Re: Denial of health insurance claim because of not getting precertification
Posted by CAH127
Posted by neener1211
Oh man, I can only tell you that I am still fighting a procedure from April of 2008. I have my HR person looking into it every time the doctor sends me a letter asking for payment.
We finally found that my insurance plan states that my DOCTOR has to ask for precertification, that it is not my responsibility. So, that loophole shoes that the doctor is at fault and I don't have to pay because I had no idea I needed prequalification since the doctor was in my plan.
Sorry you are going through this too. I always thought it was the office's responsibility. Have you appealed with the insurance company? They tell you that you are not responsible to pay it, but what are you supposed to do, ignore bills from the doctor? This is ridiculous. I am waiting for some kind of letter in the mail so I can respond with a letter of my appeal. What insurance do you have? I have BC/BS.
Stated in my plan, it IS the doctor's job to call for precertification. I actually thought this may have been resolved as of late, but nope, got another bill yesterday for the amount. I have to bring all my paperwork back into work tomorrow to deal with it...again. Oh, I have Healthnet insurance.
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| Posted 3/24/09 3:09 PM |
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