Insurance Delaying payments

[Mikew2]

What is the name of your state? What is the name of your state? Arizona

I'm having a problem with my insurance company delaying payments both to the Doctors office and myself.

I recieved a EOB ( Explanation of Benefits ) stating that more information is required to rule out a preexisting condition on my
knee. I had a accident in May 2003 while descending some stairs and subsequently injured my knee by tearing my left lateral meniscus.

Unnfortunately this condition will require surgery to correct my knee.

Occasionally, the insurance company will send requests for additional information eg medical history, and previous certificate
of creditable insurance. I have complied with their requests
by sending the information via certified mail so I know they have recieved the required information.

I feel that I am getting the run around as now I am getting the EOB's stating that I havent responded to their requests thus causing the delay or denial of benefits. Can someone tell me how to overcome this problem?

Thank you !

 

[cbg]

The fact that you sent it by certified mail does not mean it was received by the appropriate people within the company. Just that it got to their mail room.

Have you tried calling them? The insurance carrier I worked for would often accept the answers to supplemental requests for info over the phone.

 

[Mikew2]

Thank you for your response,

Unfortunately, that's what I was doing in the beginning and between giving them supplemental information over the phone and sending other information via mail. I elected for certified mail
thinking that would be my proof that the mail was recieved

I keep getting EOB's stating that I havent cooperated with their
requests therefore they cant process my claims.
I'm getting stonewalled between the CSR's, claims processors and the mail room.

I just need ideas on how to break through this problem

 

[MellowCat]

If you want to get to the bottom of this, here's the game you will have to play while they do their Pre-existing Condition investigation...

Call the insurance company to confirm they've received ALL of the information they need from you. It can take them 30 days or so to "log" the information into their systems. If they say they don't have your information, tell them you have proof it was rec'd. Then, just to make sure they're not withholding anything...

Ask them if they are requesting information from other physicians or hospitals. They most likely are, which might be the cause for the delay. If so, find out every doctor they are asking information from. (Some ins. companies don't want to divuldge this information, though as the policyholder, it seems you would have a right to know since YOU know which doctors you have seen anyway.)

Ask them which doctors they HAVE rec'd information from and which doctors they are still waiting on information from. Write it all down. Call the doctors that have not sent the requested information. They might not have even received a request for information from your carrier. If not, call your carrier and tell them they have no record of a request for information and to please send it to you so you can give it to the doctor yourself.

Continue calling the insurance carrier and the doctors to make sure the information is being handled by all parties involved. Unfortunately, pre-existing investigations can be rather labor-intensive affairs. The doctor(s) staff should be handling this on your behalf so they can get paid for services, but your insurance company may be asking for information from doctors that have no information to furnish. These investigations often turn up leads that have no basis for their investigation and only make the process stall further.

If they say they don't need any other doctors' information and maintain they still haven't rec'd your info, offer to fax the information to them one more time and keep a fax record showing it was received. If they continue stalling after that, send a copy of your Certified card and the fax journal to your state's Dept. of Insurance with a complaint letter.