AboutLinda Woolsteen Expertise I can help you with questions about health insurance. If you feel your insurance company is mistreating you. Are they telling you they are checking eligibity, pre-existing, etc. Or you just don`t understand how your insurance works or don`t understand what a PPO is.. I can help you.
Experience
Past/Present clients One company I worked for I was the underwriter for the Academy of Medicine of Cleveland and the Ohio Bar Association. I was also a supervisor of our customer service department.
Question My daughter takes medication for eplipsey and sees her neurologist every six mos. He does a blood test each time to check the medication level in her blood (venipuncture, comp metabolic, lamotrigine, and cbc. This is the first time that our insurance denied the expense as 'routine', and routine tests are not covered. Blood tests are usually 100% covered under "diagostic and treatment services', while only specific routine tests are covered under 'preventive care'.
Can I dispute their assessment of 'routine' as her visits are not preventive? If so, how best to word it?
Thanks.
Answer Hi,
The doctor's office must have submitted the bill with a "v" code which is routine, as the diagnosis code. Just ask the doctors office to resubmit the bill with the diagnosis code for eplipsey. The doctors office should indicate on the bill that it is a "Corrected Claim" and they should include the office notes for that date of service which will back up their change in the diagnosis code. I would tell them to make sure they write it very large somewhere on the bill (CORRECTED CLAIM). You should watch for your new EOB (Explanation of Benefit form) to come through and review it. Since it has already been processed by your insurance company, a lot of times, it will get kicked out as a duplicate claim. So, if your EOB for this Date of Service comes back to you stating it is a Duplicate, that is what happened & then at that point you will need to contact the insurance company & tell them to pull it & have it re-reviewed because it was not a duplicate claim, that it was a resubmitted claim with a different diagnosis. Now, sometimes, the doctor's office when you ask them, will resubmit the claim without actually changing the diagnosis code. So, when you call your insurance company (if you have to because it gets denied as a dup) and if they tell you it was processed correctly as a dup. you may want to just verify with them that the diagnosis code used on the dup bill is different than the first bill that was originally processed. Usually, they are not suppose to give you the diagnosis code, since you have to get the medical information from your doctor, but they can surely advise you if it was billed differently from the original bill and just answer that question for you.
