How do I get this health insurance reimbursement claim completed?

July 11, 2020 9:16 AM

I filed a claim with my health insurance for reimbursement for a $2500 facility fee paid out-of-pocket for a pre-approved procedure. After many iterations with customer support, their current (last?) requirement is that a representative from the facility must call them to provide a location code. Trouble is -- a representative already has.

Fortunately a contact at the facility has been willing to help me. At my request, this facility contact called my health insurance yesterday and provided the location code. (It took her two tries, because the first day she called, my health insurance's "system was down.")

Today I called my health insurance to ask about the status of the claim, and the rep again said the claim was missing the location code. I told the rep that the facility called it in yesterday, and the rep said there was no record of that. I provided the contact info for my facility contact, the rep then said she was making a note that I said the call had been made, and she said I would get a call back from the health insurance "commitment department."

So far I have received no call back.

What is the most effective way to proceed?

Additional details:

- I've provided the location code myself, but the health insurance reps say they need to hear it from the facility (?)

- I have been assured by at least one rep that the location code is all that is needed to complete my claim.

- I've asked if there is a single health insurance rep who can be the point person on this claim, but the rep I spoke to said (in effect) that's not how it works.

- I have contemporaneous notes on all my communications about this claim.

- In describing her call to my health insurance, the facility contact said "they are telling me that they will not reimburse you because you agreed to pay out of pocket for services." If true, that's news to me. But there's nothing for me to act on until I hear that from my insurance.

- Overall I would consider my health insurance to be good. It's only this particular claim that has become a debacle.

At this point, how do I get this done? Do I ask the facility contact to call again? Ask my health insurance about another contact option, like fax or mail? These could also be lost or ignored. This contact has been willing to help, but it takes nudging, and I don't want to waste her time.

How long do I try before I try something else (e.g. a complaint to my state's department of managed health care)?

(It's 24, by the way. The location code is 24.)

posted by AteYourLembas to Work & Money (2 answers total)

Best answer: When I've had this level of issue with my health insurance, we sorted it out by doing a three way call between the insurance company and the facility that was providing the information they needed (in my case it was a code that had gotten mid-coded and needed to be fixed in order to get the claim paid and for some reason all attempts to make this fix were reported as not done by my insurance). You may be able to have the rep on the phone make the call with you on the line and complete this transaction. If that is a non-option, the usual way to push this stuff through is to escalate, as well as, of course, document, document, document.
posted by jessamyn at 9:56 AM on July 11, 2020 [6 favorites]

If you can't get the three way call going, you should ask your contact at the facility to get a replacement bill sent out with the correct location code on it. Sometimes the right data doesn't get on the bill and insurance companies feel like they have no responsibility to pay if they can reject your claim for any reason. That sounds like what is happening here. They don't want to just take your word on the location code, they need it on the claim. My source is that I used to work for a medical billing software company. We had to help with a lot of issues like this by adjusting our code to allow for correct data to pass over, or instruct/assist the facility to adjust the data in the clearinghouse.
posted by possibilityleft at 6:25 AM on July 13, 2020 [1 favorite]