BCBSGA Claim Group Claim Help Needed

[somarco]

I have seen the screen cap of the EOB for medical and Rx.

Total eligible claims for the year have exceeded the $5,000 deductible.

Rx deductible is combined with major med . . . single deductible.

EOB shows claims submitted in one column and claims allowed toward deductible in a second column. Claims allowed clearly exceed deductible.

Since this was first posted, my client has filled another Rx and was not charged, possibly indicating Express Scripts now knows she has satisfied the deductible.

She is still out of pocket in xs of the deductible.

Supposedly the claim has been escalated but I don't believe anything until we are further along.

 

[Ann H]

What a mess. Your clients are lucky to have you, instead of a NAVIGATOR!

 

[LGilmore]

could it be possible they are doing a claims review on it? Most I work with use a 10K claim threshold for individual review, but maybe this one doesn't.

Is the claim in suspense now/

 

[ABC]

I would have the carrier audit all the claims.

 

[somarco]

Claims not in review or audit. Most of the claims are routine (for her).

This is not one claim but several small ones over a 2 month period of time.

Most claims were under $400 but one (gross $12k, approved amount $3960) was out of the ordinary. That claim was adjudicated and repriced on 2/15.

Rx claims started 1/10, medical claims began 2/7 and most were routine.

 

[LGilmore]

Repriced? Out of network? Could some portions of the billing be outside the U&C?