Re: Insurance Authorized It, Now they are Denying It??

[Guest guest]

In a message dated 1/12/02 6:44:34 AM Pacific Standard Time, debstar@... writes:

So imagine my surprise when we got an explanation of benefits form stating that they weren't paying for it ($2200) since it was an out of network provider. Is this right?? Can we get authorized and then turned down? The company name was on the letter authorizing it... I don't understand how this works. Any ideas??? Help!

Sounds to me like they authorized the tx but only if you got treatment from an innetwork provider and in that case, the company who treated you guys should have told you that they were out of network. Did you look to make sure that they were in network before hand? I hate insurance companies. I deal with them routinely in my line of work ( I work for surgeons) and I just hate them. Somehow though I feel like the company who provided the service has some obligation to let you know that they were out of network. Just my $.02 worth. Jen

[Guest guest]

I have to agree with Jen-you can get preapproved- so to speak-but you also

need to make sure the provider is part of the network. Although I do believe

if they were out of network they have an obligation to tell you that up front

so that you know that you will have a deductible or whatever to pay!

beck

Ps be careful of the " verification of benefits does not guarantee coverage "

statement

[Guest guest]

Hey Debi what did the company say when you called them to ask about the pre

auth letter Vs the statement of benefits received?

beck

[Guest guest]

It could be possible that there is no IN network provider for a helmet/band for you to go to. Or, if there is, be sure to check if that provider is FDA approved. In a case where there isn't an in network provider, or the in network company is not FDA approved, you may be able to fight this denial. If there is no one to help you in network, you must go out of network!!

Good luck, and keep us posted.

Kendra in Canada

Re: Insurance Authorized It, Now they are Denying It??

In a message dated 1/12/02 6:44:34 AM Pacific Standard Time, debstar@... writes:

So imagine my surprise when we got an explanation of benefits form stating that they weren't paying for it ($2200) since it was an out of network provider. Is this right?? Can we get authorized and then turned down? The company name was on the letter authorizing it... I don't understand how this works. Any ideas??? Help! Sounds to me like they authorized the tx but only if you got treatment from an innetwork provider and in that case, the company who treated you guys should have told you that they were out of network. Did you look to make sure that they were in network before hand? I hate insurance companies. I deal with them routinely in my line of work ( I work for surgeons) and I just hate them. Somehow though I feel like the company who provided the service has some obligation to let you know that they were out of network. Just my $.02 worth. Jen For more plagio info

[Guest guest]

What does that statement mean, exactly? That they don't have to pay?

Christi in TX

Mommy to , 6/2/01 at 34 weeks

http://www.exracers.com/nathan.htm

> Ps be careful of the " verification of benefits does not guarantee

coverage "

> statement

[Guest guest]

At 11:29 PM 1/12/02 -0500, you wrote:

I have to agree with Jen-you

can get preapproved- so to speak-but you also need to make sure the

provider is part of the network. Although I do believe if they were out

of network they have an obligation to tell you that up front so that you

know that you will have a deductible or whatever to

pay!

On the letter authorizing the helmet, the company we are using was named,

so I thought they were part of the network.

Ps be careful of the

" verification of benefits does not guarantee coverage "

statement

That statement is on the letter. What does that mean???

Debi and (StarBand 11/29/01)

[Guest guest]

Basically yes-when you call them to verify if you have coverage for something

they make this disclaimer that if they have verified that you have the

benefit does not necessarily mean you will automatically be covered for it

and that they must review the claim to be sure you meet all of their criteria

before they will pay the benefit out. If this is the case then ask for

documentation for their specific criteria to qualify for coverage of that

specific benefit and go from there. Hope this helps/

Beck

[Guest guest]

I work for a company that administers health insurance policies. That

" verification of benefits does not guarantee coverage " statement means that

you have coverage, but ONLY if you meet certain criteria. Whether or not you

meet that criteria is often at their discretion. You may have durable medical

equipment coverage, HOWEVER, if they do not deem it medically necessary, or

if it is not FDA approved or if you see an out-of-network provider when an

in-network provider was available then they can deny coverage even after

pre-certification. You, of course, have the right to appeal their decision

and you should. If that statement is on your pre-cert form then they do

indeed have the right to deny. You will hear that statement probably every

time you call your insurance company when asking about benefits. It is a

catch-all cover your bottom statement and all insurance companies use it. It

is very unfortunate because most people do not really understand it at all.

I'm sorry to hear about your trouble - insurance companies really are quite

awful (in general) in the United States. I feel that we truly do need some

healthcare reform!

Marci (Mom to )

Oklahoma