Hey all. First time in this subreddit.
I don’t know much about health insurance besides the things I’ve been reading here and there recently. My mother got a lumbar epidural done @ a clinic. She needs 3 done, has gotten 2 done. She has Fidelis – Medicaid Managed Care. The 1st one was covered for sure, we got Fidelis’ approval letter. But the 2nd one, we received a notice saying “review extended.” This clinic isn’t the best at customer service so I asked a doctor my mom and I know much better about the notice. The doctor quote on quote said, “Your new doctor should’ve authorized the service PRIOR to getting it done.” I checked out the dates of both the 1st and 2nd shots’ claims. Checks out, they submitted it within 1.5 weeks AFTER the service.
So I call the clinic and they said, “we submitted the additional docs already.” The appt is tmr for the 3rd shot, IDK if the 2nd one is even cleared. My mom, who speaks a language other than English, heard from the front desk just 10 minutes ago over a phone call that the shot ISNT covered and begged that she does something about it (aka call the insurance). The front desk even said “a lot of people’s services aren’t covered recently.”
Then just 2 minutes ago, I got a text from the front desk saying it’s authorized (what the f—). So within 8 minutes, the shot went from “it’s not covered” to “it’s covered?” I don’t trust them b/c IDK if they even know the rules. I certainly don’t.
Few questions:
(1) Services must be authorized PRIOR to it being administered? I saw the Fidelis handbook, and it seems like that’s not the case but I’m so confused. The digital handbook gives me a chart of what needs prior auth and it seems like the service doesn’t (huh?)
(2) Who should I call @ the health insurance company to ask about auths? I read that auths are reviewed/approved by someone that’s NOT in-house? Is that right? Wrong?
(3) What’s the best plan forward? Because it seems like a medical facility in business for 10+ years can’t even tell me what’s happening. Somehow the doctor is rank in the top 5 of the state… smh…
(4) If #1 is true, then should I call our HARP manager to call the clinic and tell them that prior auths need to be done? Our HARP mgr tends to call every doc my mom sees and he can weed out BS but I need to figure out if the shot is even covered first.
Thx. Provide more health ins info if you want, even if unrelated. I’m happy to read ’em.
submitted by /u/blendedchocolates
[link] [comments]
Hey all. First time in this subreddit. I don’t know much about health insurance besides the things I’ve been reading here and there recently. My mother got a lumbar epidural done @ a clinic. She needs 3 done, has gotten 2 done. She has Fidelis – Medicaid Managed Care. The 1st one was covered for sure, we got Fidelis’ approval letter. But the 2nd one, we received a notice saying “review extended.” This clinic isn’t the best at customer service so I asked a doctor my mom and I know much better about the notice. The doctor quote on quote said, “Your new doctor should’ve authorized the service PRIOR to getting it done.” I checked out the dates of both the 1st and 2nd shots’ claims. Checks out, they submitted it within 1.5 weeks AFTER the service. So I call the clinic and they said, “we submitted the additional docs already.” The appt is tmr for the 3rd shot, IDK if the 2nd one is even cleared. My mom, who speaks a language other than English, heard from the front desk just 10 minutes ago over a phone call that the shot ISNT covered and begged that she does something about it (aka call the insurance). The front desk even said “a lot of people’s services aren’t covered recently.” Then just 2 minutes ago, I got a text from the front desk saying it’s authorized (what the f—). So within 8 minutes, the shot went from “it’s not covered” to “it’s covered?” I don’t trust them b/c IDK if they even know the rules. I certainly don’t. Few questions: (1) Services must be authorized PRIOR to it being administered? I saw the Fidelis handbook, and it seems like that’s not the case but I’m so confused. The digital handbook gives me a chart of what needs prior auth and it seems like the service doesn’t (huh?) (2) Who should I call @ the health insurance company to ask about auths? I read that auths are reviewed/approved by someone that’s NOT in-house? Is that right? Wrong? (3) What’s the best plan forward? Because it seems like a medical facility in business for 10+ years can’t even tell me what’s happening. Somehow the doctor is rank in the top 5 of the state… smh… (4) If #1 is true, then should I call our HARP manager to call the clinic and tell them that prior auths need to be done? Our HARP mgr tends to call every doc my mom sees and he can weed out BS but I need to figure out if the shot is even covered first. Thx. Provide more health ins info if you want, even if unrelated. I’m happy to read ’em.
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