BCBSGA Claim Group Claim Help Needed

[somarco]

Small group with 9509SX HDHP. Client hit $5k in March ($4600 + $1000 Rx) and claims is telling her she has not yet satisfied her deductible IN SPITE OF the fact their online claim recap shows otherwise.

She has called claims twice. Both times they were rude. Last time (4/12) they promised a supervisor would call.

Has not happened.

I just learned of this yesterday. My rep claims she does not know anyone in claims and tells me to call the agent no-help line.

Looking for some help here. Anyone with a name and contact info of someone high up in small group claims would be appreciated.

I promise not to invoke your name when raking these idiots across the coals.

 

[leevena]

Hi Bob. Hope all is well with you and your family. I obviously do not have any contacts with the carrier, but something did come to mind. The plan has a $10K combined family deductible. Is that why the rep says they have not met the deductible. Don't know for sure, just a thought. Have a good day.
lee

 

[somarco]

Hi Lee.

True, but the plan is $5k per person, $10k per family.

The $5k is just on one person.

 

[leevena]

Hi Lee.

True, but the plan is $5k per person, $10k per family.

The $5k is just on one person.

Yes, but doesn't the plan require the $10k be incurred first. I have not heard the term "combined" but I believe it means the 2+ contracts need to satisfy the family deductible.

 

[Dave020]

Yes, but doesn't the plan require the $10k be incurred first. I have not heard the term "combined" but I believe it means the 2+ contracts need to satisfy the family deductible.

It depends on whether or not the plan has an "embedded" deductible/OOP.

Embedded plans mean that each family member on the plan must only meet the per-member deductible/OOP before that member escapes to 100% co-insurance.

Non-embedded plans mean that the family in total must meet the family deductible/OOP before any member escapes to 100% co-insurance.

Most plans are now aggregate, meaning that any combination of member expenses counts towards the total family liability.

You can have aggregate-embedded, aggregate non-embedded and both non-aggregate (rare).

One of the problems I find is that some of the carriers out here take a willy-nilly approach to embedding the deductibles (this plan has it but these two don't and all three are in the same HSA family of plans).

 

[somarco]

This is a 2 person group.

Husband is one employee and certificate holder, wife is 2nd employee and a separate certificate holder.

No dependents.

Yes, the plan does (seem) to read that benefits are payable once the family deductible is met but that is a moot point in this case.

 

[DS4]

2 seperate $5000 deductibles.

 

[somarco]

2 seperate $5000 deductibles.

Not sure where you are going with this? Are you saying you don't believe BX will pay until both employees have met their separate deductibles?

 

[Bruce]

I'm not familiar with BCBSGA but I would guess one explanation would be that the $4600+$1000=$5600 you refer to might reflect submitted claims and perhaps ineligible charges are enough to keep your client under the deductible.

I don't know what the online claim recap you refer to shows but I'd probably start with finding out if any submitted claims/claim amounts are being kicked out for being in excess of U & C or other reasons.

 

[LGilmore]

Have you seen the claim?
Does the RX have a deductible?
Are those her portion of the bill or the entire bill?
Are there any claims discounts?