Doctor in network but their office isn't: Appeal?

[leevena]

Difficult to give you a correct answer, not enough info. And, you may not like some of the following.

1. Just because a doctor is in-network does not make this visit an in-network. The administrator may only recognize participation at the group level, not the provider level.

2. Referral by primary is irrelevant. Responsibility for going to an in-network provider resides with the patient, not the primary.

3. Office let’s another provider care for your wife is irrelevant, not their responsibility.

4. Wife submitting form, with writing is irrelevant.

5. Just because a provider is listed on website as participating is irrelevant. Small print, so to speak, explains this. Again, it is the patients responsibility to verify participation.

6. NPI could be irrelevant. Again, go back to how the contracted, is it the group level? As per your ISSUES comment #1, it appears the group is contracted, not the individual.

7. Issue #2. The $5000 benefit is secondary to whether the expense is in or out of network. I have not seen the spd, but it more than likely has wording that identifies the benefit amount for the OON expense as a much lesser amount. And, you may have a large deductible for OON expenses. Difficult to help without spd.

Sorry, but based on what you have explained, it appears that you used an OON provider.

 

[ltravisjr]

Thanks for taking the time to explain this in detail. It seems after all the steps we took along the way, that we were still irresponsible and/or not diligent enough. I will ask my employer to stress how much homework we need to do to ensure we aren’t surprised like I was.

 

[ltravisjr]

One last thing. Is an in network provider required by law to submit claims for its patients, and is so where could I find that law? I thought I had read something about that somewhere.

 

[leevena]

Probably not required by law. Keep in mind that each state regulates insurance, so it is possible, I am not familiar with each states law. And, if your group is self-funded, which it may be, then state laws are pre-empted. Provider contracts have provisions in them that describe claim submittal process.

I do not work in the Medicare and Medicaid space, but I believe they are required to do so.

 

[ltravisjr]

Probably not required by law. Keep in mind that each state regulates insurance, so it is possible, I am not familiar with each states law. And, if your group is self-funded, which it may be, then state laws are pre-empted. Provider contracts have provisions in them that describe claim submittal process.

I do not work in the Medicare and Medicaid space, but I believe they are required to do so.

Ok, thanks. Our insurance customer service rep had said it was the law but through this whole ordeal I have learned that I can't trust even him; only actual contracts and legal documents.