Guest guest Posted February 12, 2008 Report Share Posted February 12, 2008 I do not have any real knowledge of how to deal with ins. and appeals - But just a common sense question... Do they deny EVERY dr you see in SC because they are outside CA? Just a thought. :-) Jen and Luli - 26 months Left tort - Right Plagio - Hanger Band Grad - CA http://www.babiesonline.com/babies/j/jens5th/ BCBS of CA Our insurance company is BCBS of CA, but we live in SC. We had our son fitted for a band at CT in NC. CT is in-network for BCBS of CA, but since our services were not rendered in CA, they are saying that it is not covered as an in-network provider. Has anyone else dealt with a situation like this? Just wondering whether I should look into it further or if this sort of thing happens a bunch. We are deciding on a second band and need to budget accordingly. Any info would be helpful...thanks so much!! Staci More new features than ever. Check out the new AOL Mail! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 13, 2008 Report Share Posted February 13, 2008 Well, the insurance company isn't denying it. They are considering CT to be in-network. CT is saying it's out of network. We paid up front for the band....$3000. I filed the claim and Blue Cross processed with the member in-network discount (which is $1200 dollars). So basically, they are saying we only owe $210 (our coinsurance is 10% for in-network) and CT is responsible for the $900 which we over payed. BCBS of CA Our insurance company is BCBS of CA, but we live in SC. We had our son fitted for a band at CT in NC. CT is in-network for BCBS of CA, but since our services were not rendered in CA, they are saying that it is not covered as an in-network provider. Has anyone else dealt with a situation like this? Just wondering whether I should look into it further or if this sort of thing happens a bunch. We are deciding on a second band and need to budget accordingly. Any info would be helpful...thanks so much!!Staci More new features than ever. Check out the new AOL Mail! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 13, 2008 Report Share Posted February 13, 2008 OH - so If I understand correctly - You paid $3000, BCBS paid you back $1200 - and you are wanting a $900 refund from CT becauce yuo overpaid - but CT says they are out of network so they owe you nothing? Seems like CT needs to talk to BCBS - Maybe BCBS worked out a deal with CT in Cali - but not SC. So SC won't take $1200 - they want the full $3000 - what does BCBS say about this? Jen and Luli - 26 months Left tort - Right Plagio - Hanger Band Grad - CA http://www.babiesonline.com/babies/j/jens5th/ BCBS of CA Our insurance company is BCBS of CA, but we live in SC. We had our son fitted for a band at CT in NC. CT is in-network for BCBS of CA, but since our services were not rendered in CA, they are saying that it is not covered as an in-network provider. Has anyone else dealt with a situation like this? Just wondering whether I should look into it further or if this sort of thing happens a bunch. We are deciding on a second band and need to budget accordingly. Any info would be helpful...thanks so much!! Staci More new features than ever. Check out the new AOL Mail! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 13, 2008 Report Share Posted February 13, 2008 what about other providers? ie when you go to a primary care i would assume you dont go through the bcbs ca list but you go through bcbssc.com or bluecares.com??? b/c if you went through bcbs ca all the sc providers would be out of network??? so if CT is not listed on BCBS SC I would expect that it isn't " in network " so thats why CT is saying that and you arent getting the contracted amount but insurance is paying it like it is CT in CA b/c it is billed to CA??? I dont know it all sounds confusing. See I am trying to think about how things work for us. We are in SC but my husbands company is in CA. His company is self insured though so all the healthcare bills are ultimately paid for through a healthcare administration company. But the healthcare administration company is contracted with BCBS of CA so BCBS CA does the actual contracting and recieves all the claims. But on our insurance card it says for providers to submit to their local BCBS. So if I go to the doctor or whatever they enter me in the system as having BCBS of SC. So to get an in network provider I have to look on the BCBS SC listing b/c it is initially sent to local BCBS and CA listing nothing in SC would be considered in network. So my OB for instance is in network for BCBS SC so they have a contracted amount with BCBS SC (a few hundred less than the OBs global fee) so when they go to bill they discount my bill to the contracted amount then they bill BCBS for the full amount, BCBS discounts it to their contracted amount then they send it to the healthcare administration comapny (or maybe BCBS CA who sends it to them???) and the healthcare administration pays their percentage of the BCBS contracted amount and the rest is my responsibility. I guess for me and providers it doesnt seem too bad b/c we just treat it like BCBS SC but there is a lot behind that I guess. Anyway for us CT Charlotte is not in network with BCBS SC and we were told BCBS SC rarely pays for the band anyway, they typically deny it and you have to appeal so we wanted to avoid that so what we did was call HR at dhs company, they set us up with a case worker with the healthcare administration company. she skipped BCBS completely and dealt with us, the healthcare administration she works for and CT. She preapproved us (even though we dont need preapproval, thsi assured us that we would actually get our $$) to not only get it covered but get it covered in network based on the measurements and such from CT. She said that BCBS CA had a contract with CT and that their company had previously worked out a deal with CT so she tried to give finance to work out another contract but they were too busy and she didnt want to delay his treatment so we ended up not getting to do that and since we couldnt do that CT wouldnt bill them directly (she tried to work that out with CT Charlotte herself). So instead we had to pay up front (we paid in full so it was $2700) but instead of submitting it like we usually submit a claim we had to fax the claim to her which bypassed BCBS and so we got our check faster (in 3 days) and got it covered without appeal and in network bassed on the full amount we paid. On Feb 12, 2008 2:15 PM, stacihyde <shyde@...> wrote: Our insurance company is BCBS of CA, but we live in SC. We had our son fitted for a band at CT in NC. CT is in-network for BCBS of CA, but since our services were not rendered in CA, they are saying that it is not covered as an in-network provider. Has anyone else dealt with a situation like this? Just wondering whether I should look into it further or if this sort of thing happens a bunch. We are deciding on a second band and need to budget accordingly. Any info would be helpful...thanks so much!!Staci -- SC SAHM to , , and " A large family " , the Pope remarked, " constitutes a witness of faith, courage, and optimism. " Moreover, large families provide wealth to society, " because without children there is no future! " Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 13, 2008 Report Share Posted February 13, 2008 BCBS of CA basically said that CT should have filed the claim in the first place instead of having me file it myself out of network. CT's insurance coordinator told me that they can not afford to contract the $2100 rate for the band nationwide and BCBS of CA processed my claim incorrectly and they really have nothing else to do with it. BCBS of CA Our insurance company is BCBS of CA, but we live in SC. We had our son fitted for a band at CT in NC. CT is in-network for BCBS of CA, but since our services were not rendered in CA, they are saying that it is not covered as an in-network provider. Has anyone else dealt with a situation like this? Just wondering whether I should look into it further or if this sort of thing happens a bunch. We are deciding on a second band and need to budget accordingly. Any info would be helpful...thanks so much!!Staci More new features than ever. Check out the new AOL Mail! Quote Link to comment Share on other sites More sharing options...
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