How do these ind plan insurance co,s determine if they can cover your hospital bill?

Question

I really need your help.Im trying to find information about b cross or b shieldHas any one been covered by them for inpatient or hospital stay? or works in an dr office that knows how insurance co. determine if they can cover you? what are some tips from people w/ similar experience wth them?do you know what reasons they try to eliminate or underwriters use to not cover you?It would be life saving..please give as much details if you had similar exp. or if you know how they work ,its an individual plan if thats any help...thanks

Answer 1

BCBS has many different policies. They have HMO's, PPO's, comprehensive policies and basic policies. The policies available in one state may be completely different from the policies in another state. What one policy covers will be completely different from what another type of policy covers.

You'll need to read your policy or ask your agent to find out what is covered. They will cover what they say they cover and exclude what they say they'll exclude. The doctor or hospital also has to code the procedure correctly to receive coverage. If you have a question about some procedure that was not covered you'll need to contact BCBS directly. Ask why it wasn't covered. If you still think it should be covered you can appeal.

Answer 2

Okay. Let me see if I can make sense of this question. Forgive me if I'm wrong, but it was REALLY difficult to read it.

You're saying you already have insurance with Blue Cross/Blue Shield, and you want to know if they're going to cover your hospital stay. That depends on several things: 1. Do you have hospital coverage? 2. Is the hospital you're going to use in-network? 3. Are you having something done that is covered? In other words - if you do not have hospitalization coverage, or the hospital is not in your network, or you're having something like cosmetic surgery - you will not be covered.

In theory - because no one regulates insurance companies - they can pretty much do whatever they want with a claim. As long as you follow the rules of your plan - i.e. using participating providers, getting any necessary authorizations, and knowing what your plan limitations are - you should be okay. You may need to fight with them a little to pay everything they're supposed to, because insurance companies like to deny things, but if it's in your contract that they are supposed to pay for X,Y, and Z then YOU need to be pro-active in enforcing that.

Good luck!