PLAYER57832 wrote:B. You are very, very seriously underestimating the roadblocks Blue Cross, in particular puts up. I suspect if you have any experience with them, it is with their Highmark plan.. not Keystone, not Select Blue or any of the other lower options they offer. I have had all and can assure you there is a BIG difference.. and I am someone who actually got them to pay things they have denied initially. BUT.. it took me an average of 3 months PER COMPLAINT for over 2 years. It ended because our insurance ended. The only visits not questioned were for me, when I was pregnant.
AND.. before you start saying "isolated example".. that experience led me to do a more than a little investigating and questioning. Every doctor to whom I spoke mentioned similar experiences. They all saw repeated denials of claims --for reasons that always varied. Sometimes "the wrong code" was used -- even though the code was the one the office as given by the company. Sometimes the company would just claim the item was "not covered".. Remember that the literature you get from the company is not the legal contract.. and generally there is some kind of notation that this "explanation of benefits" -- or whatever is "not legally binding".
Out of curiosity, was the plan you are talking about through an employer plan, or an individual plan purchased directly from the insurer? There are many plans a company can purchase and the coverage varies dramatically. Just like car insurance... if you pay extra for comprehensive for your car and you drive it off a bridge, the insurance company will pick up the replacement cost (less the deductible). If you only have liability, then they won't, because you didn't pay for that level of coverage. If a service was expressly stated as covered in your EOB, and they didn't cover that service, I hope you had a lawyer look at the case, because that certainly doesn't sound like something that can be done within the same plan year legally.