I had top surgery with a surgeon out of network on 1/26/2021. When I got the date set for my surgery (around November 2020), I started the process of filing an out-of-network claim. I called my health insurance company several times for pre-auth and was told three separate times that I meet the criteria for coverage and do NOT need pre-auth and everything could be done after the procedure. I have my letters from my therapist at the time and a letter from another professional stating that the surgery was a necessity, which is what they required. I get the procedure and I file the out-of-network claim. I send the claim with the forms they need (the two letters and the bill with procedural codes, cost breakdowns, etc). They reply with a letter in the mail stating that I did not give them what I need. I need to provide them with a bill. Okay, maybe something messed up. I send it again. They send another letter that they need my out-of-claim form. Okay? I send both things again. This goes on for MONTHS. I finally call and ask what’s going on. He tells me that I needed a pre-auth for my surgery and I tell him I was told several times that wasn’t the case. He says okay I’ll talk to my manager. He comes back after a few minutes and says “okay this is all messed up. We need your claim form and your bill again. and we’ll give you a call when we receive it.” I wait weeks, no call. I get a letter to send everything again. I do. I wait. I call again. Finally, someone who is willing to help me. She talks to her manager, she tells me everything is messed up. She wants to take a week to work everything out with her manager and that she will call me back and I express my anxiousness about it because nobody has followed through with it. She does and she asks me to fax her directly my forms and she will call me back. The fax was sent successfully on 1/27/22. No call back. So I call today and I’m transferred to 4 different people telling each one the rep I’m looking for. I finally get someone who tells me she’s not in today. Okay, whatever, I ask if he can help me. And he says it they’ve never received the fax or that it wasn’t processed. I’m beyond frustrated. I have sent them what the surgeon’s office has sent me several times. It has all the information they’ve asked for and the rep today even said that’s what he would think they are asking for. He said he would call me back or have the rep I was asking for call me back. I don’t believe them and at this point, I am just ready to pop off. Is there anything that I can do to expedite this process? Should I get a lawyer involved? This battle has been going on for almost a year and a half, the loan I took out to pay for the procedure is lingering over me since I lost my job. I only did this because I was assured at least part of the procedure would be covered. Any advice is appreciated. The insurance company is Capital Blue.
TL;DR: Insurance company is asking me for the same two documents over a period of a year and a half and telling me I needed a pre-auth code for a procedure I had done out of network even though I was told several times I didn’t need pre-auth.
submitted by /u/GayAGayMusical
[link] [comments]I had top surgery with a surgeon out of network on 1/26/2021. When I got the date set for my surgery (around November 2020), I started the process of filing an out-of-network claim. I called my health insurance company several times for pre-auth and was told three separate times that I meet the criteria for coverage and do NOT need pre-auth and everything could be done after the procedure. I have my letters from my therapist at the time and a letter from another professional stating that the surgery was a necessity, which is what they required. I get the procedure and I file the out-of-network claim. I send the claim with the forms they need (the two letters and the bill with procedural codes, cost breakdowns, etc). They reply with a letter in the mail stating that I did not give them what I need. I need to provide them with a bill. Okay, maybe something messed up. I send it again. They send another letter that they need my out-of-claim form. Okay? I send both things again. This goes on for MONTHS. I finally call and ask what’s going on. He tells me that I needed a pre-auth for my surgery and I tell him I was told several times that wasn’t the case. He says okay I’ll talk to my manager. He comes back after a few minutes and says “okay this is all messed up. We need your claim form and your bill again. and we’ll give you a call when we receive it.” I wait weeks, no call. I get a letter to send everything again. I do. I wait. I call again. Finally, someone who is willing to help me. She talks to her manager, she tells me everything is messed up. She wants to take a week to work everything out with her manager and that she will call me back and I express my anxiousness about it because nobody has followed through with it. She does and she asks me to fax her directly my forms and she will call me back. The fax was sent successfully on 1/27/22. No call back. So I call today and I’m transferred to 4 different people telling each one the rep I’m looking for. I finally get someone who tells me she’s not in today. Okay, whatever, I ask if he can help me. And he says it they’ve never received the fax or that it wasn’t processed. I’m beyond frustrated. I have sent them what the surgeon’s office has sent me several times. It has all the information they’ve asked for and the rep today even said that’s what he would think they are asking for. He said he would call me back or have the rep I was asking for call me back. I don’t believe them and at this point, I am just ready to pop off. Is there anything that I can do to expedite this process? Should I get a lawyer involved? This battle has been going on for almost a year and a half, the loan I took out to pay for the procedure is lingering over me since I lost my job. I only did this because I was assured at least part of the procedure would be covered. Any advice is appreciated. The insurance company is Capital Blue. TL;DR: Insurance company is asking me for the same two documents over a period of a year and a half and telling me I needed a pre-auth code for a procedure I had done out of network even though I was told several times I didn’t need pre-auth. submitted by /u/GayAGayMusical [link] [comments]Read Morer/HealthInsurance