Denial of Daughters Claim

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What is the name of your state? Oregon I'll try to make this short but give you as much info as possible.

First off I received a statement from a lab that was outside of our provider network. Our insurance plan is that if we go inside of our provider network than our co-pay is $10 and $15 if outside of provider. I received a statement from the lab for my daughters diagnostic culture. I had the exact same test done and have the Insurance EOB for mine and the same and the covered it completely.

But now for my daughters which was back in october they said that they have applied it to the deductible for $97 which when I look at the statement from the lab itself that is the entire bill. Plus we have no deductible. I have called and called and called and they told me that they would need this and that which the lab and us provided for them and they would send it too revue. I just got a call today from the supervisor that said they were going to uphold for the denial and that they would send out a denial letter and that if I wanted to talk to her I could but she I repeat was not going to through it with me until the denial letter was sent. But I could call and ask questions but again she wasn't even going to explain it to me as to why the claim was denied.

I need help were not sue happy people but we don't like being pushed around and were just not sure what to do. Help

Please

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[cbg]

A couple of questions that are not clear in your post, but are key to providing an accurate answer:

1.) Did you pick the lab, knowing that it was out of network and aware that the benefits would be different, or was the sample taken by a network doctor or hospital, who then sent it to a lab which proved to be out of network?

2.) When you had the test done, was it done by the same lab as your daughter's?

3.) How old is your daughter?

4.) Do you have an HMO, PPO or POS plan? (If you don't know the difference, let me know and I'll explain them. It matters.)

I have a couple of ideas as to what might have happened, but need the above questions answered to confirm which idea is actually the case. What you can do is going to be determined by which idea, if any, is correct.

 

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denial of daughters claim

1) No.... I went to a referred specialist by my family physician.
Absolutely no control over choice of lab.

2) Checked with husband and he said he thought we had a PPO

3) Our daughter is 11-years-old

My daughter legally has my maiden name as we haven't gotten it changed over to my married name yet. However, we specifically put the name highfenated with her legal name not to confuse the billing company.

Thank you,

 

[cbg]

You missed the question as to whether or not your test was done at the same lab as your daughter's. I need that, too.

 

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denial of daughters claim

Sorry about that it was early this morning when I read your reply.

Yes it was at the same lab as mine was done.

I just talked to the lab this morning and they said that even though it was the same test the physcian put a different code. Should I contact the physcian to see if they can change it? or just wait at this point?

 

[cbg]

If the physician put down a different code, that very well could be the problem and I would definitely recommend that you contact the physician about it. Don't just wait; the physician isn't going to change the code if no one brings the problem to his attention, and as far as the insurance carrier is concerned, they are required to go by the code that's there.

Check with the physician first. If he put down the wrong code in error, he can resubmit the claim with an explanation. Once that is done, if you still get the same result, post back here (do me a favor and don't start a new thread - use this one so I can see what I've already got) and I'll give you some other possibilities. Based on your answers I have a pretty good idea what is probably the problem IF it turns out not to be the coding issue, but the wrong code is the most likely.

 

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denial daughters claim

Sure I will use this thread for further posts. Thank you for your quick responses and will call them now the physcians office and see what we can get. I will let you know once I know.