Anyone work in health insurance? Help!

[ElizK]

DH took the girls skiing in March. DD13 (now 14) broke her ankle and badly sprained her knee while skiing. DH had her treated there at the ski resort rather than driving the 1 1/2 - 2 hrs to Taos for treatment at the hospital. We had to pay cash for the treatment, and then submitted everything to insurance to be reimbursed. It was denied 100% because she was treated "out of network". I'm planning to appeal this, and am looking for any advice as to wording that I can use in my appeal.

Another thing I noticed is that they didn't even apply the out-of-network deductible, which would have at least reimbursed me about $80.00 of the $618.00 we paid. I'll go that route if my appeal doesn't get me anywhere.

Thanks for your help!

 

[Honu]

I don't work in insurance, but I do know that on our company's policies you have to call the provider at the time of service (or shortly thereafter in an emergency) when you are being treated outside of a coverage area. If you don't, it's not covered.

 

[barkley]

mine would'nt cover any of it if it happened out of state (unless it was "life threatening"). if it happened in state but away from our network i'de have to call and get pre-authorization for treatment if i wanted any kind of reimbursement (they would likely direct me to a contracted provider unless we were transported by ambulance in which case they would probably cover a portion of the "triage" but then if needed have me transferred).

 

[kelleigh1]

You should find the information in your schedule of benefits, but yes, coverage for treatment outside of your provider network needs to be either pre-approved or in some cases you must contact them within a limited period of time - most likely 24 hours.

(FWIW...I worked in the health insurance field for 15 years, and left the field 2 years ago.)

 

[manchurianbrownbear]

I work in health insurance but, not being familiar with your policy, I don’t know that I can be a great help!

You’re probably doing the right thing by appealing the denial of this claim. What do you have to lose, right?!?!

If you’ve obtained your coverage through an employer, you may have more success if you ask someone in HR/Employee benefits to look into this for you. I work in the Sales Department and I can tell you that if a “decision maker” from one of my employer groups asks us to look at a claim, it’s going to get looked at!

 

[ElizK]

Hmmm. This isn't sounding very good. Tough lesson to be learned. And expensive.

DD14 goes for an MRI on that knee tomorrow. That'll cost me 168.00, plus all the dr visits, etc.

Would have been a whole lot cheaper had my DH put the kids in ski school, rather than trying to teach them himself.