Ok Come on man this cant be reality??

[scagnt83]

The provider is saying they are looking inot it and needs more time, so it might get fixed I am just trying to see what my legal recourse will be if they try and charge us 12K

We did do everything we were supposed to do

Sue them for breach of contract.

 

[vic120]

If the provider wants to get paid.....they should file the claim properly. The provider needs to refile the claim including the PA.

Good luck.

That all sounds right but I felt the same way when I went an earlier time and they took down all my ins information on the phone and 2 times at the place and never told me they were not in network

even after being referred there by the primary

that all landed on me

so this time I wanted to be sure I would not be out of pcet again

 

[LeeV]

1 No the Preauth was not submitted with the claim by the provider
That is the problem

WE (MY WIFE) did get the authorization our seves gave it to the provider and the provider did not include it when submitting the claim

this is WHY we are being told it was declined

2 No it was NOT sumited the provider was supposed to submit it to the carrier when submitting the claim they failed to do this

3 YES my WIFE obtained the preauthorization

4 My WIFE forwarded it to the provider for the service

Ok, so now it is starting to make sense. According to your posts, the provider never included the preauthorization with the original claim submittal causing the claim to be denied. Your appeal was declined because of a lack of preauthorization. If this is true, the carrier/administrator was in the right.

I would suggest you call the customer service dept of the carrier. Explain the situation that the provider never submitted the preauthorization and that you have a copy and will submit it. This should take care of it.

And by the way, since the preauthorization was never submitted you cannot sue them for breach of contract or any other reason. The carrier/administrator was correct in denying the claim without a preauthorization.

 

[LeeV]

He is saying that the doctor did not submit the pre-autho with the claim they sent to the carrier. Now the carrier is denying it, despite fixing the mistake and sending both together.

Read his reply below. No one has submitted a preauthorization to the carrier/administrator. His wife did obtain a copy of the preauthorization and gave it to the provider.

 

[vic120]

Ok, so now it is starting to make sense. According to your posts, the provider never included the preauthorization with the original claim submittal causing the claim to be denied. Your appeal was declined because of a lack of preauthorization. If this is true, the carrier/administrator was in the right.

I would suggest you call the customer service dept of the carrier. Explain the situation that the provider never submitted the preauthorization and that you have a copy and will submit it. This should take care of it.

And by the way, since the preauthorization was never submitted you cannot sue them for breach of contract or any other reason. The carrier/administrator was correct in denying the claim without a preauthorization.

I am not getting this, Ok the carrier is right what does that mean

Am I wrong and responsible to pay provider??

Or is the provider responsible for THIER mistake?

I am really confused because If I did not submit something right and caused harm to one of my clients I would be held to the cross

Why are there providers able to just take advantage of people?

Should not the provider be the one to suffer loss for their mistake??

They were the one who submitted things wrong to the carrier

I mean seriously what other industry would they be off the hook legally speaking?

I am really struggling on how or why this falls on me

We did by the way explain everything to the carrier and they said all they can say is file an appeal and we did and it was denied

 

[LeeV]

I am not getting this, Ok the carrier is right what does that mean

Am I wrong and responsible to pay provider??

Or is the provider responsible for THIER mistake?

I am really confused because If I did not submit something right and caused harm to one of my clients I would be held to the cross

Why are there providers able to just take advantage of people?

Should not the provider be the one to suffer loss for their mistake??

They were the one who submitted things wrong to the carrier

I mean seriously what other industry would they be off the hook legally speaking?

I am really struggling on how or why this falls on me

We did by the way explain everything to the carrier and they said all they can say is file an appeal and we did and it was denied

The carrier is right because preauthorization is required, and according to your posts, no preauthorization has been submitted to them. They must adjudicate the claim as written in the plan docs.

Ultimately, you are responsible for paying the bill.

Since you have the preauthorization do as I said earlier, call customer service and fix it. Yes, it was the providers' responsibility, but you have a quick and easy way to remedy this problem.

 

[vic120]

The carrier is right because preauthorization is required, and according to your posts, no preauthorization has been submitted to them. They must adjudicate the claim as written in the plan docs.

Ultimately, you are responsible for paying the bill.

Since you have the preauthorization do as I said earlier, call customer service and fix it. Yes, it was the providers' responsibility, but you have a quick and easy way to remedy this problem.

I get why the carrier is not wrong

But why am I wrong? I did everyting right

why is the Provider not wrong they are the ones that submitted the claim wrong

what am I missing here I am not getting it

In fact any time this has happened to a client it was simple just have the provider resubmit and there was never an issue

but these people are acting like its an issue

But seriously I am lost here I am not getting why if the Ins carrier is not wrong why does that make me responsible when the provider made the error

help me get this

just explaining why the carrier is not wrong is not helping

 

[rousemark]

I get why the carrier is not wrong

But why am I wrong? I did everyting right

why is the Provider not wrong they are the ones that submitted the claim wrong

what am I missing here I am not getting it

In fact any time this has happened to a client it was simple just have the provider resubmit and there was never an issue

but these people are acting like its an issue

But seriously I am lost here I am not getting why if the Ins carrier is not wrong why does that make me responsible when the provider made the error

help me get this

just explaining why the carrier is not wrong is not helping

Vic, situations like this are the reason I pay Legal Shield every month. Sometimes a letter from a lawyer will get things done. Also, file a complaint with your DOI. They might not take action but they will investigate. Sometimes that is enough.

 

[scagnt83]

Read his reply below. No one has submitted a preauthorization to the carrier/administrator. His wife did obtain a copy of the preauthorization and gave it to the provider.

As I understood it, the Facility resubmitted the claim along with the Pre-Autho. Still denied.

 

[vic120]

As I understood it, the Facility resubmitted the claim along with the Pre-Autho. Still denied.

No I have not yet had any word that anything was resubmitted, only this i know is the claim was submitted without the preauth attached