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  1. #1
    triomom171 is offline Junior Member
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    Provider did not file insurance in timely manner

    What is the name of your state? NC

    We have a medical bill that is in question (over 18 months old).We have only just now found out that this may not have been filed.There was no contact from the provider company saying there was a problem with this bill. Is our insurance responsible or is the provider that did not file responsible? Have contacted insurance company. They state that they have no record of this being filed.The provider that was supposed to file says that they think that they did file. We also found that some other charges were not filed by provider with another insurance, but we found out in time to correct this and our other insurance has paid for the other bills. In all of this the provider made no mention of the fact that they were experiencing difficulties. We found out through gossip . Also we have found out that the provider has not been filing our secondary insurance (Medicare). Terrible mess and we need to know who is responsible for the bill.
  2. #2
    lealea1005 is offline Senior Member
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    Quote Originally Posted by triomom171 View Post
    What is the name of your state? NC

    We have a medical bill that is in question (over 18 months old).We have only just now found out that this may not have been filed.There was no contact from the provider company saying there was a problem with this bill. Is our insurance responsible or is the provider that did not file responsible? Have contacted insurance company. They state that they have no record of this being filed.The provider that was supposed to file says that they think that they did file. We also found that some other charges were not filed by provider with another insurance, but we found out in time to correct this and our other insurance has paid for the other bills. In all of this the provider made no mention of the fact that they were experiencing difficulties. We found out through gossip . Also we have found out that the provider has not been filing our secondary insurance (Medicare). Terrible mess and we need to know who is responsible for the bill.
    Ask the provider to provide you with copies of their proof of insurance submission for the dates of service in question. If they file electroncially, there will be a list with dates. If they file by paper, they will have a copy of the HCFA1500 form. Typically, if the provider is contracted with your insurance company, they must submit the claim within your insurance company's "timely filing" period. If they are contracted with the insurance company, and the insurance company denes the claim because it was not filed within the timely filing period, the provider cannot collect from the patient.
  3. #3
    triomom171 is offline Junior Member
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    More info.

    Hi:
    We have been waiting to hear from the insurance company. They continue to claim that they did not receive this filing. The provider (pharmacy) claims to have no proof of filing. Says that it is too old (August 2005). Are we responsible or is the pharmacy? Should we contact our State Insurance Department?
    Thanks for any information!
  4. #4
    justalayman is offline Senior Member
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    speak with your insurance company to see if there is a cotractual relationship with the pharmacy. If there is such a relationship, ask them if there are rules such as lealea stated. If so, then let the pharmacy and the insurance company duke it out, it is actually between them.

    If there is no such relationship, then tell the pharmacy they did not address this within a reasonable time and based upon the doctrine of laches, you should not be billed since their delay has caused you to be unable to address this with the insurance company or redirect the charges to any other insurance company that may have been in place to pay for the claim.
  5. #5
    ecmst12 is offline Senior Member
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    Filing with the secondary insurance is frequently the patient's responsibility. But if the pharmacy participates with your primary insurance, then the dispute is between your insurance and the pharmacy. If the pharmacy cannot prove to your insurance that they submitted the claim timely, then that is their loss, they cannot bill you.
  6. #6
    justalayman is offline Senior Member
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    Quote Originally Posted by ecmst12 View Post
    Filing with the secondary insurance is frequently the patient's responsibility. But if the pharmacy participates with your primary insurance, then the dispute is between your insurance and the pharmacy. If the pharmacy cannot prove to your insurance that they submitted the claim timely, then that is their loss, they cannot bill you.
    and that is where laches applies. The provider did not notify the OP within a reasonable time so they could file with the secondary insurance. Pharamacies fault here as well.
  7. #7
    triomom171 is offline Junior Member
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    Hi:
    Since I last posted we have contacted our State Department of Insurance. They recommended that we send a letter of appeal (which we did and requested a confirmation of receipt of letter), wait 30 days for a decision (which they will most likely deny). When we receive that letter the State Department of Ins. told us to file a 2nd letter of appeal asking that the claim be reviewed by an external panel. After a 30 day period if the insurance company has still denied this claim, then the State Department of Insurance adviises us to contact them (State Dept.) and file a complaint. Has anyone out there had any experience with this procedure? Will this work or are we just prolonging the inevitable? Thanks for any advice or insight!!!
  8. #8
    ecmst12 is offline Senior Member
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    Find out if the pharmacy participates with your primary insurance. If so, tell them that their dispute is with your INSURANCE COMPANY and not with you.
  9. #9
    triomom171 is offline Junior Member
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    I need to clarify. When you say, "find out if this pharmacy participates with this insurance" what does that mean? My husband had surgery 19 years ago that resulted in his needing a great deal of medication. He had the same insurance during this time and it is the one that the pharmacy submitted charges to for all those years. The insurance company has always been very timely about payment. Until he had surgery again in May of 2005 and we noticed a slowing of payments. Both my husband and I are confused by who is responsible for this confusion over payment. We have spent a great deal of time, money on phone calls and have had a lot of distress over this.
  10. #10
    ajkroy is offline Member
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    Participation means that your pharmacy has a contract with your insurance to provide you with medications and you only pay a copay. Contracts frequently change from year to year, so just because they were on a contract before, it doesn't mean that they still are now. It is your responsibility to know which pharmacy you can use, just like you are supposed to know which doctors and hospitals can treat you.

    Medicare didn't have a drug policy in 2005, so did you have a different secondary insurer then?

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