Question
Hi Tricia,
I tried submitting a claim to my insurance co. (NY) for visits to a nutritionist due to gestational diabetes during my pregnancy. The nutritionist did not participate with my insurance co. I submitted the bills as out of network claims. Insurance co. came back and said they needed a procedure code. I called the nutritionist office and was told that I couldn't submit to the insurance co. because they charged me less than if they would have if they had excepted my insurance. If they had participated with my insurance they would have charged me $54 more. Don't I have a right to submit out of network charges? Can this nutritionist office tell me not to? Is this legal or am I clearly in the wrong here? Very confused.
Thanks!
Answer
Hi Pam!
You always have the right to submit a claim to your insurance company even if you paid up front for a charge. If your nutritionist is not in your network then they can not bill but in most cases the patient can go out of their network and just get reduced benefits.
The nutritionist probably charged you a "private pay" rate meaning they thought your insurance would not pay so they gave you a break.
I would assume they called your insurance carrier and was told that they would not pay for this type of service. This is usually why a provider would give you a private pay rate.
Go ahead and bill your insurance carrier to see if they will pay......worth a shot. Your insurance contract is between you and your carrier, not the provider. If they will not give you the procedure code, look it up on the Internet.
Good Luck!
Tricia
