Should I be concerned about my insurance company asking for my HIPAA Certificate?

December 23, 2009 7:20 AM

I received a letter from my new health insurance company stating "they have received a claim for an illness that could be related to a pre-existing condition." What now?

The letter further explains "because your plan has a pre existing condition limitation I am required to provide a HIPAA certificate."

Some backstory: I have been seeing a therapist for depression/ADD/anxiety and have been prescribed many Rx as we try and find the right combination for me. This started under my previous insurance about eight months ago.

I can provide my current insurance provider a HIPAA certificate from my previous ins. company, that's no problem. But for some reason this situation is setting off alarm bells and has me concerned. Is there anything I should be doing besides sending the HIPAA certificate?

posted by anonymous to health & fitness (7 answers total)

As long as you did not have a break in coverage and can provide the certificate proving so, you shouldn't have any problems.
posted by something something at 7:22 AM on December 23, 2009

If you didn't have a break in coverage of more than 63 days and you can provide the certificate of creditable coverage, you should be fine.
posted by Pax at 7:31 AM on December 23, 2009

Reply by letter. As you can see from the attached documentation, I have had uninterrupted coverage for this condition. Save every scrap of documentation. Every state has an insurance Commission call them if you have questions. IANAL, etc.
posted by theora55 at 7:49 AM on December 23, 2009

Lots of people get alarmed about this stuff too! The rules are confusing if you are not acquainted with them, and the consequences of not fulfilling the right requirements are scary. But you will probably be fine.
posted by grouse at 8:06 AM on December 23, 2009

I believe the pre-existing exclusion is for up to 18 months. So if you have only 8 months of previous insurance, they can stick you with 10 months of pre-existing wait time. I think you need to show them 18 months of insurance over the previous 18 months to be completely in the clear.

But I'm not 100% on that. If your insurance is through an employer the HR department should be able to help you.
posted by COD at 8:42 AM on December 23, 2009

Sometimes insurance companies go fishing; at least, mine does. Every time something happens that they will have to pay out big on, such as a recent surgery I had after meeting my out-of-pocket limit for the year. They sent me a coordination of benefits form in the hopes that I will turn out to have other insurance that can be made to pay part of it. They may just be hoping you had an interruption in coverage so they can unload some costs.

I thought that you could only be hit with pre-existing condition denials if you'd had a break in coverage, though I am not an expert. Since I have chronic conditions, if new insurance could make me wait a year or more for coverage, they surely would. But like the first couple of replies, I think you'll be OK.
posted by not that girl at 9:22 AM on December 23, 2009

This is, most likely, a minor administrative thing. Follow up, in writing, as previously suggested. If you get any backtalk from the plan, and you know you're in the right, contact your state's insurance commissioner. Actually, you can contact them with any questions you have, too.

not that girl has the reason for this. The insurance plan will make money in two ways: by denying claims and by people not using any benefits but paying premiums. It has been said (anecdotally) that health plans automatically deny a certain percentage of claims because it's so unlikely that people will challenge the denials. It's just their business model. Fortunately you have prior coverage and can obtain a certificate, so this shouldn't be an issue for you.
posted by FergieBelle at 10:22 AM on December 23, 2009