Insurance Question about Coverage

Lipstickdiva · ‎03-10-2010

I know I need to contact the plan administrator about this but I am just wondering if anyone has ever heard of this situation because I haven't before.

I have health insurance with DH through his employer. It's referred to as employee + 1 coverage and it's through BCBS. We have had this coverage for 7 years. Every year, I have routine bloodwork done which includes having my cholestrol checked.

This year, I rec'd my EOB and everything regarding my bloodwork was paid except my cholestrol test. They denied payment on that. I called BCBS and was told it was because my physician's office coded it incorrectly.

Long story short, I received a letter indicating that under our plan, cholestrol tests are only covered for the employee, not family members. This has to be a new change as it's always been covered in the past. But this doesn't make any sense to me. If we are paying for coverage, I don't understand how they will pay for coverage of some things for only 1 person on the plan and not everyone?

I'm going to look into this further but wondered if anyone ever ran into this and if it's common.

terrier3 · ‎03-10-2010

@Lipstickdiva wrote:
I know I need to contact the plan administrator about this but I am just wondering if anyone has ever heard of this situation because I haven't before.

I have health insurance with DH through his employer.  It's referred to as employee + 1 coverage and it's through BCBS. We have had this coverage for 7 years. Every year, I have routine bloodwork done which includes having my cholestrol checked.

This year, I rec'd my EOB and everything regarding my bloodwork was paid except my cholestrol test. They denied payment on that. I called BCBS and was told it was because my physician's office coded it incorrectly.

Long story short, I received a letter indicating that under our plan, cholestrol tests are only covered for the employee, not family members. This has to be a new change as it's always been covered in the past.  But this doesn't make any sense to me. If we are paying for coverage, I don't understand how they will pay for coverage of some things for only 1 person on the plan and not everyone?

I'm going to look into this further but wondered if anyone ever ran into this and if it's common.

I don't work in CS - I sell policies - but this is weird.

Was this part of your annual "well" visit? If so, it should be included at NC.

Unless you have a chronic problem and are on meds for that issue. Then it wouldn't be a free well visit, but ongoing treatment.

May I suggest that you talk to the MDs billing department and see if they can re-code it and send back to BCBS?

straykatz · ‎03-09-2010

I does sound like a coding issue. Have you contacted your doctor office? I had a similar thing happen to me a couple years ago and my doctor resubmitted without question.

Big Sister · ‎05-15-2010

You're right, I think, this doesn't make sense. Your doctor's biller should resubmit the claim with the correct coding.

Winkk · ‎03-15-2010

It may be a coding mistake by your doctor's office. I read that a lot of new codes were added the beginning of October, the office may have put in the wrong one.

GCR18 · ‎07-03-2013

I'd call BCBS back and talk with someone else. I just spent six weeks straightening out 2 bills they declined. Their final outcome was one bill would be paid, but not the other because it was experimental. Nothing about my radiation treatments were experimental. The next day I went into my BCBS page and they paid the bill their rep told me wouldn't be paid.

2blonde · ‎03-10-2010

I hate to say it, but what the insurance company is telling you may be true. I have a friend who works with me, and her husband worked here also (he's recently retired). When he was here he was the primary insured and she was the dependent on their employee provided insurance. (By using only his coverage, she received a $2,000/yr rebate on her paycheck for not having her own policy as an employee. There were certain tests and preventative procedures that were not covered for her, but were covered for him under the plan.

Laura loves cats!

straykatz · ‎03-09-2010

@GCR18 wrote:
I'd call BCBS back and talk with someone else. I just spent six weeks straightening out 2 bills they declined. Their final outcome was one bill would be paid, but not the other because it was experimental. Nothing about my radiation treatments were experimental. The next day I went into my BCBS page and they paid the bill their rep told me wouldn't be paid.

Got to love those reps....I recently argued with my dental insurance because they said I had 3 cleanings in 1 year and I am only allowed 2. So what happened was my checkup got scheduled 2 days too early which meant I went 3 times in a 12 month period. Seriously!!!....I was wild!!.....and only after I flipped out did she offer to cover it as a one time courtesy because I went 2 days too soon. How ridiculous is that!

Lipstickdiva · ‎03-10-2010

This was part of my well visit and it's not no charge because DH's insurance doesn't have to follow the new HC laws yet so they aren't. I still had to pay for my mammo this year too.

First I was told when I called that it was a coding issue. So I called my doctor's office and they said it was coded correctly and they absolutely were not going to recode it.

I called BCBS again and spoke to someone different. To me there was no way it could be a coding issue because all my other bloodwork was paid, it was just the cholestrol that was denied. It was paid last year and she went back and looked and it was coded the same way last year as this year. The rep put me on hold, came back and said that a supervisor said it needed to be sent back to another dept. and given an override code and would be paid. Then as the girl was e-mailing the other dept., she read in my contract that a cholestrol test wasn't covered for me, only my DH. She said she was submitting it anyhow to see what happened. About a week later I received the letter indicating this test wasn't covered for me and if I had further questions, I needed to contact the employer.

I left a message at DH's employer for them to call me back about this. I know I saved my insurance book but do you think I can find it? Of course not.

kitty60 · ‎03-13-2010

I have BC in SC and every year I have to go a round with them to have my phyical paid as it should be. I can pull up my coverage on their site and clearly see what it covers. I then refer them to the site. It can take me up to three reprocessings to get it paid! Don't give up.