I had to use an out of network provider who does not do insurance. I paid in full for services, The employer pays the first $1000 of the deductible per my policy. How do I get that back?
I apologize for the confusion. According to your specific benefit plan, the dollar allowance ($1000) is one that is eligible for services performed in network. The following is what is outlined in your benefit plan certificate.
This certificate contains a network provider benefit allowance. This allowance applies to the first $1,000of covered expenses for services received from network providers incurred by you per year. Benefitsprovided under this allowance are payable by us at 100% after copayments, if any, and are not subject tothe annual deductibles shown in this "Schedule of Benefits" section. The network provider benefitallowance is not applicable to covered expenses for preventive services, or any benefits under the"Prescription Drug Benefit Rider" attached to the master group contract.Once the total amount of covered expenses for services received from network providers exceeds theallowance stated above, any additional covered expenses for services from network providers will besubject to the annual deductibles, if applicable, and any copayment and/or coinsurance as specified withinthis "Schedule of Benefits" section.
You can view your certificate via the following instructions outlined here: How do I find out my benefit information?
The claim was processed as in network for the amount that was allowed (which is peanuts for 5 hrs of anesthesia by a pediatric anesthesiologist) vs what I was advised before having the procedure done.
In any case if they paid the claim based on in-network I should receive reimbursement by the employer for the first $1000 of the $1250 deductible as stated in the policy. So far I have received $143 for $4300 of anesthesia. I also had to pay $150 per tooth out of pocket for 20 fillings totaling $3100. A few months ago Joanna’s mom (Jean McKnight) on the same policy had a large filling replaced for $100 copay.
What is so criminal is that there are no in-network dental anesthesia providers for those with disabilities. I had trouble finding an in network dental provider. The first one I went to ( who advertises sedation dentistry) did X-rays, an exam , and said they would have to do the work on certain day at another facility. They never called me back and told me not to call them after I inquired about a date 3 or 4 times over the next 4 weeks. I had to go to another provider in the county next door for the care. Their anesthesiologists they use don’t “do insurance “.
So the law requiring insurance to pay for anesthesia is toothless and irrelevant.
For this crappy insurance we pay $11,000 per year plus an upfront $350 drug deductible for my daughter and me. That is almost 20 percent of my husband’s ( a teacher) income. One would think that the school system who employs hundreds of thousands of employees could negotiate better coverage for that price.
Thank you for the additional detail. I reviewed the claim further. While this provider was out of network, as the services performed were related to anesthesia, Humana allows for an exception to process the claim using the maximum allowable fee towards your in network allowance of benefits. This is separate from the allowance you are given by your employer. In order to receive this particular benefit, the provider would have to be in network.
I apologize for the inconvenience, and hope you are recovering well.
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