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HMO primary and PPO secondary - Went to PPO hospital for Labour, will I have to pay out of pocket?

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#1
What is the name of your state? California

Hi - My wife has dual coverage, one from her employer which is Kaiser HMO plan (recently added) and one from my employer which is Aetna PPO plan (Been with it for 2 years), she recently gave birth to a baby and we went to Aetna's covered hospital, only to realize towards our discharge that hospital mentioned Aetna may deny the claim and we have to pay out of pocket. Could you please let me know if hospital sends the claim first to HMO plan, then if I submit to Aetna PPO the EOB from HMO plan, will Aetna consider it, or outrightly denies it as primary denied it, though it doesn't make sense. I am in a situation where paying dual premiums and also going through this issue. Any help is much appreciated.
 


cbg

I'm a Northern Girl
#2
This is why it rarely makes sense to have two policies unless the secondary policy is significantly better than the primary.

Yes, Aetna will consider it. They are required to review every claim that comes in to them. But not having read either of the two policies, I have no idea whether or not they will pay any portion of it. The likelihood is that they will pay that portion of the bill that they would have paid, had they been the primary carrier. But I cannot carve that for you in stone.

The bottom line is yes, it's quite possible that you may have an out of pocket charge. But how much of the overall charge it will be, I can't say.

BTW, while you will have to send the EOB to Aetna, you will also have to send them an itemized bill. They cannot and will not pay from an EOB alone, even if they do find the bill to be payable.
 
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