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
