I used to work for a medicare insurance broker helping retiree clients navigate the bureaucratic nightmare of insurance. So I have some competence in dealing with them. But I have a specific question regarding the 180 day appeal deadline, which is common in health insurance.
I was at a rehab facility for 3 weeks in 2020, they were in network, provider submitted multiple claims for my time there. The first claim was accepted and paid on by the insurance. The following claims were all denied but with no denial reason on the claims. The provider told me that it was because my “benefit tier was exceeded.” I have no idea what that means and neither do they. Member services at the insurance don’t have any idea and can only tell me that there is no explanation of the denial on the claims. They are equally confused by the benefit tier thing and as far as they can tell, the claims should have been covered.
Background:
I paid the provider everything I initially owed and then they said I was all paid up. After I completed my payments, the provider told me there were some claims they were trying to settle with the insurance, but they were confident that I was all settled up as far as payments to them. Around Dec 2021, they told me that insurance had denied those claims (the benefit tier exceeded) and I now owe the remainder. They said the outstanding balance was like $50k or something outrageous but they would bill me for that amount as though I was self paying and cut me a deal–I’d owe them $11k. And I’ve resumed payments on that balance.
I’ve begun taking very detailed notes as I fight this, because I believe these claims should be covered–same facility, same service, same everything; and they covered the first claim. My out of pocket max (for everything, including medical and mental health) is $7,400, so I believe that is the most I should have to pay. I plan on fighting it to the death. So this is where appeals come in.
I’ve been told that provider appeals carry more weight and the provider has said they had sent in an appeal. I brought up the 180 days deadline, which clearly has passed. But they said that each time they got a denial, they re-appealed it, restarting the clock.
Most recently, they had sent in an appeal in February 2022. But just a few days ago, insurance has no record of this appeal. I called the provider and they confirmed that for some reason the insurance didn’t get the appeal, so they are reviewing the appeal submission guidelines and re-submitting. I think it has to be in writing.
If things don’t go well with the provider appeal, I intend on submitting my own appeal, including every little detail.
So my concern is how vague the provider is about what appeals they submitted, when, and if they even reached the insurance. I think it’s likely that insurance would consider me way outside of the 180 day window. Do I have a chance of winning an appeal by pointing out that the provider didn’t even notify me about this until around Dec 2021. I’m at the mercy of their negligence and they (and I) are apparently at the mercy of the insurance’s negligence.
Question 1: what does “benefit tier exceeded” mean?
Question 2: is it possible to win an appeal outside of the 180 day window if the provider didn’t notify me about this in time? And factoring in that I was newly sober, readjusting to life, and living in sober living for 2 months after I got out of treatment; I have no recollection of EOB’s during that time.
tldr; I wasn’t notified of denied claims within the 180 day appeal timeframe. Is there precedence that I can win an appeal?
submitted by /u/callthedoqtr
[link] [comments]I used to work for a medicare insurance broker helping retiree clients navigate the bureaucratic nightmare of insurance. So I have some competence in dealing with them. But I have a specific question regarding the 180 day appeal deadline, which is common in health insurance. I was at a rehab facility for 3 weeks in 2020, they were in network, provider submitted multiple claims for my time there. The first claim was accepted and paid on by the insurance. The following claims were all denied but with no denial reason on the claims. The provider told me that it was because my “benefit tier was exceeded.” I have no idea what that means and neither do they. Member services at the insurance don’t have any idea and can only tell me that there is no explanation of the denial on the claims. They are equally confused by the benefit tier thing and as far as they can tell, the claims should have been covered. Background: I paid the provider everything I initially owed and then they said I was all paid up. After I completed my payments, the provider told me there were some claims they were trying to settle with the insurance, but they were confident that I was all settled up as far as payments to them. Around Dec 2021, they told me that insurance had denied those claims (the benefit tier exceeded) and I now owe the remainder. They said the outstanding balance was like $50k or something outrageous but they would bill me for that amount as though I was self paying and cut me a deal–I’d owe them $11k. And I’ve resumed payments on that balance. I’ve begun taking very detailed notes as I fight this, because I believe these claims should be covered–same facility, same service, same everything; and they covered the first claim. My out of pocket max (for everything, including medical and mental health) is $7,400, so I believe that is the most I should have to pay. I plan on fighting it to the death. So this is where appeals come in. I’ve been told that provider appeals carry more weight and the provider has said they had sent in an appeal. I brought up the 180 days deadline, which clearly has passed. But they said that each time they got a denial, they re-appealed it, restarting the clock. Most recently, they had sent in an appeal in February 2022. But just a few days ago, insurance has no record of this appeal. I called the provider and they confirmed that for some reason the insurance didn’t get the appeal, so they are reviewing the appeal submission guidelines and re-submitting. I think it has to be in writing. If things don’t go well with the provider appeal, I intend on submitting my own appeal, including every little detail. So my concern is how vague the provider is about what appeals they submitted, when, and if they even reached the insurance. I think it’s likely that insurance would consider me way outside of the 180 day window. Do I have a chance of winning an appeal by pointing out that the provider didn’t even notify me about this until around Dec 2021. I’m at the mercy of their negligence and they (and I) are apparently at the mercy of the insurance’s negligence. Question 1: what does “benefit tier exceeded” mean? Question 2: is it possible to win an appeal outside of the 180 day window if the provider didn’t notify me about this in time? And factoring in that I was newly sober, readjusting to life, and living in sober living for 2 months after I got out of treatment; I have no recollection of EOB’s during that time. tldr; I wasn’t notified of denied claims within the 180 day appeal timeframe. Is there precedence that I can win an appeal? submitted by /u/callthedoqtr [link] [comments]Read Morer/HealthInsurance