Question
QUESTION: I have an insurance claim question for you (I don?t know if you can answer it, but thought I would ask). I had a surgical procedure performed in December 2008 & was pre-authorized for a CPM for use afterward. Later, UHC (my insurance company) denied my claim stating the service code did not match the diagnosis. The provider changed the procedure code, & now, the claim is being denied because UHC is claiming the provider is out of network & that UHC was not informed in a timely manner regarding the use of the CPM. I thought I remember someone telling me (a long time ago) that if insurance denies a claim, they need to provide all of the reasons for denial & once corrected, they cannot CHANGE their reason for denial. In fact, as I recall, it is illegal to do this. Does that ring a bell to you??? (Initially, they denied for the wrong diagnosis code. After correction, they denied due to being out of network & not submitting in a timely manner despite the initial letter I received that stated they had received notification in a timely manner).
Thank You in Advance for Your Time & Expertise!!
Courtney
ANSWER: Hi Courtney!
If a claim is denied due to a billing error, a provider is allowed to fix the error and resubmit with proper information. Then the insurance company reviews and processes the claim with the new information. They can now deny for another reason. There is no rule or law that I know of that an insurance company can not deny with another reason.
It happens all the time. I work for a DME company and we can fix an invoice and resubmit several times as they keep giving us new denials.
You can always appeal with UHC proving that their denial is not accurate.
Good Luck!
Tricia
---------- FOLLOW-UP ----------
QUESTION: Tricia--
Thanks for your prompt response. UHC provided a letter to me initially that stated the vendor has "met the notification requirement and no further action is necessary at this time." Then, after the error with the diagnosis code (the initial reason for denial that was on the EOB) was corrected. Now, UHC has provided the vendor (I didn't even get a copy from UHC, but had to request it from the vendor) a new reason for denial which is "the notification requirement for this health care service was NOT met & the patient's health benefit plan does not cover services provided by a non-network....professional."
Can they revoke their initial letter??
My surgery / physician were both in network & prior authorized. I had no idea that the DME vendor was "out of network" because I awoke with the device on me (ironically, the "fitting" of the device & the "coverings" for the device WERE covered). Apparently, the device was placed their during surgery.?? Can I be held responsible for this or will an appeal typically resolve it (don't worry, I know their are no absolute answers).
Again, thank you for your time!!!!
Courtney
Answer
Yes they can change their denial.
However usually UHC pays for out of network providers at a lower rate unless you have an HMO plan.
Perhaps call the Dr and asked why they used an out of network provider. They should have used one that is in your network or give you the option to say it would be okay. I would think it is sort of an error by the Dr's office not asking the provider. Perhaps the Dr's office can help you.
Before you appeal try to find out who did not do what they are suppose to do. Then find out if you have out of network benefits. Remember also UHC has time limits for appeals so do not go beyond or they will not pay.......usually it is so many days after their denial letter.
By the way, I work for a CPM company in NJ.........and if a patient is out of a network we always advise them prior to receiving our unit. Just common courtesy.
Tricia
