I visit the same out-of-network provider weekly for the same service and submit a monthly claim to my insurance company. The amounts considered eligible change so much from month to month, that I wonder if the claims are processed in a random way. Are they?
Sometimes the EOB says it used data from Dataisight to determine the eligible amount. When they do, the amount that’s considered eligible is about 25% less than the provider’s bill. So, 75% of the provider’s bill was considered eligible.
Sometimes the EOB says ” Ineligible amount based on the usual and customary provisions as outlined in your benefit plan.”, and the amount that’s considered eligible is about 5% of the provider’s bill (95% was eligible).
One time the EOB that the bill is “Paid in accordance with the Multiplan/Viant agreement”, and it was all considered eligible and 100% of the provider’s bill was applied to my deductible.
To me, it looks like how the insurance company processes these claims is random. Can anyone tell me if there’s a reason why dataisight gets used only sometimes? If I asked the insurance company about these differences, would they just reprocess everything at the dataisight rate, which always benefits them more than it benefits me?
submitted by /u/TweezleSnoofThe2nd
[link] [comments]I visit the same out-of-network provider weekly for the same service and submit a monthly claim to my insurance company. The amounts considered eligible change so much from month to month, that I wonder if the claims are processed in a random way. Are they? Sometimes the EOB says it used data from Dataisight to determine the eligible amount. When they do, the amount that’s considered eligible is about 25% less than the provider’s bill. So, 75% of the provider’s bill was considered eligible. Sometimes the EOB says ” Ineligible amount based on the usual and customary provisions as outlined in your benefit plan.”, and the amount that’s considered eligible is about 5% of the provider’s bill (95% was eligible). One time the EOB that the bill is “Paid in accordance with the Multiplan/Viant agreement”, and it was all considered eligible and 100% of the provider’s bill was applied to my deductible. To me, it looks like how the insurance company processes these claims is random. Can anyone tell me if there’s a reason why dataisight gets used only sometimes? If I asked the insurance company about these differences, would they just reprocess everything at the dataisight rate, which always benefits them more than it benefits me? submitted by /u/TweezleSnoofThe2nd [link] [comments]Read Morer/HealthInsurance