Health Insurance Claim?

Question

Hi,
I have a question on health insurance claim.
My employer provided me and my family the Pacificare PPO plan.
This plan was valid up to 03/31/2007.
Starting 04/01/2007, my employer terminated the plan with Pacificare PPO and moved to Aetna PPO.

On 03/20, my 3-year-old son had a regular checkup with the pediatrician.
The pediatrician charged about 220$ and we made the copay of $20.

The pediatrician's office sent the bill to Pacificare after 04/01/2007 and Pacificare rejected the claim made stating that we were no longer with them.

Right about a week ago, I got the bill from the doctor's office asking me to pay $200.


When my son went for the checkup, we had Pacificare. When the doctor's office sent the bill to Pacificare, we were no longer with it.

It's not our fault as it was my employer who opted out of Pacificare.

Please advise me as I made the payment of $200 to the doctor's office this morning.

Answer 1

Even if the claim was submitted after the plan termed, the date of service was still when the plan was active, so it should not have been denied. (Otherwise, nobody would go to the doctor on the last day of the month!) You should call Pacificare right away and ask them to reconsider the claim. Then call the doctor's office and ask them to refund your $200 when they get paid by the insurance. (Regardless of what the plan pays them, you get your full $200 back.)

Answer 2

Unfortunately, this type of things happens all the time. Call Pacificare and advice them that on 3/20 your son saw his pediatrician but the claim was denied stating that your coverage was not in effect but, in fact, your coverage didn't terminate until 3/31.

They may ask you to contact the doctor's office and ask them to re-file the claim because many claims now go through electronicly and cannot be re-processed or they may be able to make the payment with what they have.

If you cannot get it resolved talking with the insurance company and the doctor's office, contact your Human Resources Department. Your company pays a lot of money for your health insurance and they don't want you to paying this bill anymore than you want to pay it.

Answer 3

You have to get on the phone with Pacificare and tell them the action took place while covered with them. You have a valid claim and they are the ones who have to reimburse you. Talk with a supervisor if you have to. If you can't get anywhere with them, tell them you are writing a letter of complaint to the Dept. of Insurance in your State as well as the Better Business Bureau. You were smart to pay the bill to the Dr. as this is your responsibility but it's also the responsibility of the Pacificare to pay the bill. Maybe it's just miscommunication or they are confused. Could be simple but you have to deal with it personally. Good luck.

Answer 4

Pacificare should pay (or reimburse you, since you already paid). What matters is whether you were covered on the date of service, not the date when the claim was filed.

Answer 5

I file ins. claims all the time and this is one of the ways insurance companies try to NOT pay claims. Since your doctor's office filed the claim they need to contact the insurance company and ask them to correct the error since you were covered when the service was performed. You should not have to get involved unless the doctor is not able to correct it. Don't ever pay a doctor until you get a copy of the explanation of benefits that the insurance company sends to the doctor when they make the payment, or deny the claim. On the EOB, it will state exactly what you owe, sometimes the doctor will ask you to pay more than you are supposed to pay.

Answer 6

I agree. They may have the wrong date of services on the claim. I am dealing with a bill myself and I have insurance I believe the billing company did not submit my claim or did not send in the correct information. Hope this helps

Answer 7

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