@chrystaltree wrote:
Look it up in the insurance booklet you have, the one that explains your coverage. Use the current book. That they would cover that lab test for the employee but not for dependants just doesn't seem right. It doesn't make any sense. Before you look it up yourself, call BCBS back and ask another cs rep. It's possible that the employer changed coverage and cholesterol screeing isn't covered every year. As for your doc's office coding the cholesterol lab wrong. If that were the case, how would you or BCBS know that the denied charge was for the cholesterol test? Medical claims aren't billed with words, they are billed with procedure codes. So if the doc's office used the wrong code for the cholesterol test, you wouldn't know that. For example, if they incorrectly billed 87275 instead of the correct code for cholesteral. You would have received a denial for 87275, which is influenza B virus screening. The computer system that processed your claim would know that you had your cholesteral checked.
I don't have my book as I explained above. My DH's employer read me the section out of the coverage book and it says it's not covered for anyone but the employee. Same with the PSA test, which obviously I don't need.
I can go on-line to BCBS website and review all of my claims and the claim detail. For this particular visit, my claim detail lists everything they did that day in the lab and how much each procedure was and what my insurance paid. Next to the one that says "Lab Cholesterol" it had a code and showed $0.00 being paid by my insurance. The code was that according to our plan certificate, this isn't covered for a non-employee.
Of course if you call a rep at your insurance company, they know everything that was submitted and why it wasn't paid. I don't understand why you think the insurance company would be looking at a procedure code and not able to tell what that corresponded to. They'd have to know that.
I've now talked to a BCBS rep 3 times. Without it being recoded by my doctor's office as medically necessary, it will not be paid.