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04-20-2012 at 3:29 PM
childofhip...
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childofhiphop is not online. Last active: 02-08-2013, 10:46 AMNewbie

Health Insurance Audit?

I was very sick at the beginning of the year and the doctor, surgery center and anethesiaologist were out of network.

I've gone rounds with Blue Shield because the claims were not paid according to my PPO plan (70/30 for out of network).

Is there a way I can get my claims audited? Is it internal to Blue Shield or a 3rd party?

Any help or suggestions on how to get this started would be greatly appreciated! 

Thank you. 

 
04-20-2012 at 4:35 PM
MainelyFoo...
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MainelyFoolish is not online. Last active: 05-24-2013, 3:44 PMGold

There should be a formal appeals process with your insurance plan. If you've already gone through that and the claims are still being denied (and you think the insurance company is wrong), try your state insurance commissioner to see what remedies are available.


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04-20-2012 at 4:39 PM
almond1123
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almond1123 is not online. Last active: 11-12-2012, 6:48 AMSilver

When you say the claims are not being paid properly can you specify.

If BCBS is suppose to pay 70% that's what should be paid for any qualifying OON claims.  Did they pay less than that or is one of the doctor's offices still charging you after being reimbursed by BCBS?

 
04-20-2012 at 5:29 PM
Sisugal
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Are they paying based on  the "approved" amounts and not the acutal charges?
 
04-20-2012 at 5:54 PM
childofhip...
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childofhiphop is not online. Last active: 02-08-2013, 10:46 AMNewbie

Sisugal:
Are they paying based on  the "approved" amounts and not the acutal charges?

This is what I thought might be the issue but they will not let me know what the approved amounts are. 

 
04-20-2012 at 5:58 PM
childofhip...
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childofhiphop is not online. Last active: 02-08-2013, 10:46 AMNewbie
almond1123:

When you say the claims are not being paid properly can you specify.

If BCBS is suppose to pay 70% that's what should be paid for any qualifying OON claims.  Did they pay less than that or is one of the doctor's offices still charging you after being reimbursed by BCBS?

They've paid substantially less than the 70%. It has also been very inconsistent with payments for providers being mailed to me when I've submitted claims and specifically checked for payment to be made to the providers.

I thought that maybe the 70% that was being paid was on a different amount (set by Blue Shield for the types of services) but I can't even get that information from them when I call. 

 
10-10-2012 at 12:32 AM
franmoor
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franmoor is not online. Last active: 11-17-2012, 2:28 AMNewbie
If they can't tell you the exact details on the phone, then a visit to their office would do. Sometimes you can't really depend on customer service especially when it comes to claims.
 
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