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doctor's failure to file insurance claim

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C

cwiggins

Guest
What is the name of your state? NM.
Doctor failed to file claim for procedure performed over 6 months ago and another 2 months ago. Since then, I changed insurance companies to get more coverage. Does the previous insurance company still have to pay or is there a time limit for filing a claim? If not, am I responsible for paying?
 


cbg

I'm a Northern Girl
1. You would submit the claim to the carrier that was in effect at the time the procedure was done, not the one you're using now.

2. Most carriers have a time frame as to when a claim must be submitted; however, we have no way of knowing what the time frame for your carrier is. I've seen carriers that would refuse to pay a claim submitted more than 90 days after the procedure; I've seen carriers allow claims to be submitted for up to 15 months after the procedure. All you can do is submit it and see what they say.

3.) If the carrier refuses to pay the claim because it is beyond their time limit for payment, yes, you have to pay it.


Let me qualify #3 a bit. I should say that you PROBABLY have to pay it. It is just barely possible that your insurance coverage has a provision making you immune from paying any charges that are unpayable due to the doctor's error in submitting the claim; however that will depend entirely upon the terms of your policy. At the time the insurance company makes their payment (or denies payment) they will send you an Explanation of Benefits (EOB). The EOB will show what the charges are, what payments they made, and what you are responsible for. IF there is a provision such as I have described, your responsibility will show as $0 on the EOB; however, if there is a dollar figure ascribed to you on the EOB, then yes, you have to pay it unless you can convince the doctor otherwise. Legally, it is your responsibility.
 
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