My wife had to go to the ER in June 2021 to get her gallbladder out. At the time she was double insured with her insurance (UHC) and my insurance (BCBS). The hospital was out of network with UHC, but in network with BCBS. A week later we received a letter from BCBS saying that her condition requires an inpatient stay and that her stay would be covered. UHC also sent a letter saying her hospital stay was not medically necessary and will not cover it.
Coordination of Benefits was setup correctly and the bill was sent to UHC first, and of course UHC denied the claim. After 3 months of going back and forth with UHC they finally agreed it was medically necessary and covered the claim. The claim then went to BCBS which did not end up paying anything because the amount UHC paid was more than the BCBS member price. So we thought that was the end of it. I have EOB’s from both insurances with the approved claim.
7 Months later (April 2022) we get an EOB from UHC saying that they denied the claim and now we owe $35,000 because the hospital stay was deemed medically not necessary. We called UHC to see what’s up and sure enough they took the money back from the hospital. They said they have no idea why this happened and that they have never seen this before. They said they would have to escalate this to “complex claims” to be looked at.
How do I even go about appealing this? They already agreed it was medically necessary, how can they come back 7 months later and say “Just kidding, it’s actually not medically necessary”.
submitted by /u/sheik482
[link] [comments]My wife had to go to the ER in June 2021 to get her gallbladder out. At the time she was double insured with her insurance (UHC) and my insurance (BCBS). The hospital was out of network with UHC, but in network with BCBS. A week later we received a letter from BCBS saying that her condition requires an inpatient stay and that her stay would be covered. UHC also sent a letter saying her hospital stay was not medically necessary and will not cover it. Coordination of Benefits was setup correctly and the bill was sent to UHC first, and of course UHC denied the claim. After 3 months of going back and forth with UHC they finally agreed it was medically necessary and covered the claim. The claim then went to BCBS which did not end up paying anything because the amount UHC paid was more than the BCBS member price. So we thought that was the end of it. I have EOB’s from both insurances with the approved claim. 7 Months later (April 2022) we get an EOB from UHC saying that they denied the claim and now we owe $35,000 because the hospital stay was deemed medically not necessary. We called UHC to see what’s up and sure enough they took the money back from the hospital. They said they have no idea why this happened and that they have never seen this before. They said they would have to escalate this to “complex claims” to be looked at. How do I even go about appealing this? They already agreed it was medically necessary, how can they come back 7 months later and say “Just kidding, it’s actually not medically necessary”. submitted by /u/sheik482 [link] [comments]Read Morer/HealthInsurance