Proving a health insurance policy doesn't exist?

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dlrkw9mu
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Proving a health insurance policy doesn't exist?

Post by dlrkw9mu »

Hi,
Anyone have any experience / tips / advice on successfully appealing a health insurance claim denial?

My wife gave birth in late April, and shortly thereafter added our daughter to her (BCBS) health insurance plan through her employer. I have a separate (Cigna) plan, for just me, through my employer. I did not add our daughter to my plan, and we did not purchase any other health insurance coverage for our daughter.

In August, we received a letter from "The Rawlings Company" stating that BCBS identified other primary health insurance for our daughter, and if we are contacted by one of our health providers, to have them bill that other insurance policy as "primary". They say that the other plan identified was a Cigna plan, but give no further details. We responded to the Rawlings Company in late August stating that our daughter is not covered by any other insurance plan to our knowledge, and have not received any further communication from them.

This month we began receiving bills from our pediatrician, hospitals, etc for care provided to our daughter during April and May, with notes that the insurance company has denied the claims. We pulled up and reviewed the EOBs from BCBS for the denied claims, which state "We cannot process these charges until your other insurance plan processes them. We need a copy of their explanation of benefits (EOB) showing what they paid. Please refer to the coordination of benefits section of your benefit booklet for specific details".

We obviously plan to file an appeal, but I'm a little bit confused as to how I go about providing evidence to BCBS that no other insurance exists for her? I can probably show that she's not covered by MY Cigna insurance plan, but that really doesn't show that she doesn't have any other coverage. Any ideas? Is there a way to look up health insurance plans by SSN in the US?
Last edited by dlrkw9mu on Sat Sep 25, 2021 2:42 pm, edited 1 time in total.
Big Dog
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Re: Proving a health insurance policy doesn't exist?

Post by Big Dog »

why not call BCBS on Monday and explain that your D is covered under your wife's policy and that BCBS is primary; there is no secondary policy. They will likely mail you a form to check the box that there is no other coverage (similar to what you sent into Rawlings).

OTOH, you wife may be able to appeal thru her online BCBS account. (Blue Shield in our state of CA shows that option under Contacts/Billings...)
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Nate79
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Re: Proving a health insurance policy doesn't exist?

Post by Nate79 »

This is kind of confusing because its not clear what the insurance company said when you called them the first time and confirmed they were ok with your documentation.
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ResearchMed
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Re: Proving a health insurance policy doesn't exist?

Post by ResearchMed »

They are insisting that you provide proof that there is NOT another policy (!?), what is their evidence that she IS covered by another policy... Have them give you the details about that. Perhaps it's your own policy, in which case there should be evidence of who IS covered: you.
That *might* be enough, depending upon what that other policy they seem to have discovered is...

And then... Contact the Insurance Commissioner's Office in your state. They'll cut to the chase.

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runninginvestor
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Re: Proving a health insurance policy doesn't exist?

Post by runninginvestor »

dlrkw9mu wrote: Sat Sep 25, 2021 2:34 pm Hi,
Anyone have any experience / tips / advice on successfully appealing a health insurance claim denial?

My wife gave birth in late April, and shortly thereafter added our daughter to her (BCBS) health insurance plan through her employer. I have a separate (Cigna) plan, for just me, through my employer. I did not add our daughter to my plan, and we did not purchase any other health insurance coverage for our daughter.

In August, we received a letter from "The Rawlings Company" stating that BCBS identified other primary health insurance for our daughter, and if we are contacted by one of our health providers, to have them bill that other insurance policy as "primary". They say that the other plan identified was a Cigna plan, but give no further details. We responded to the Rawlings Company in late August stating that our daughter is not covered by any other insurance plan to our knowledge, and have not received any further communication from them.

This month we began receiving bills from our pediatrician, hospitals, etc for care provided to our daughter during April and May, with notes that the insurance company has denied the claims. We pulled up and reviewed the EOBs from BCBS for the denied claims, which state "We cannot process these charges until your other insurance plan processes them. We need a copy of their explanation of benefits (EOB) showing what they paid. Please refer to the coordination of benefits section of your benefit booklet for specific details".

We obviously plan to file an appeal, but I'm a little bit confused as to how I go about providing evidence to BCBS that no other insurance exists for her? I can probably show that she's not covered by MY Cigna insurance plan, but that really doesn't show that she doesn't have any other coverage. Any ideas? Is there a way to look up health insurance plans by SSN in the US?
Does this apply for some of the services?

https://www.insure.com/amp/health-insur ... -rule.html

Here's another article :
https://www.npr.org/sections/health-sho ... dical-bill

"
When a child is born into a family in which both parents have insurance through their jobs, the parents are supposed to "coordinate benefits'' — meaning they must tell both insurers that their child is eligible for coverage under two plans. The parents might be forgiven for thinking they have some say in how their child will be insured. In most cases, they don't.

Instead, a child with double health insurance eligibility must take as primary coverage the plan of the parent whose birthday comes first in the calendar year; the other parent's insurance is considered secondary. This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, says Lee Modesitt, director of government affairs with the Kansas Insurance Department.
"
Last edited by runninginvestor on Sat Sep 25, 2021 3:25 pm, edited 2 times in total.
100factorial
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Re: Proving a health insurance policy doesn't exist?

Post by 100factorial »

Big Dog wrote: Sat Sep 25, 2021 2:41 pm why not call BCBS on Monday and explain that your D is covered under your wife's policy and that BCBS is primary; there is no secondary policy. They will likely mail you a form to check the box that there is no other coverage (similar to what you sent into Rawlings).

OTOH, you wife may be able to appeal thru her online BCBS account. (Blue Shield in our state of CA shows that option under Contacts/Billings...)
+1

This sounds like a straightforward matter to rectify. OP, please keep us posted.
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nisiprius
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Re: Proving a health insurance policy doesn't exist?

Post by nisiprius »

Many states have what is informally called a "health insurance ombudsman." Unfortunately the exact name of the department and official varies.

Find out if your state has a "health insurance ombudsman."

About a decade ago, we were caught in a maddening runaround. Whenever I called our HMO's customer number, they said the same thing every time: a specific procedure was covered by the exact plan we were on. But whenever we called the surgeon's office, they said that when they called the same HMO's provider number, the HMO told them that the procedure was not covered. This went on for weeks. I even tried to set up a conference call, but couldn't.

So I called the ombudsman's office one morning.

By that afternoon they called back saying that the procedure was covered and that the situation was resolved. (And the procedure was performed, and the insurer did pay for it).
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exodusNH
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Re: Proving a health insurance policy doesn't exist?

Post by exodusNH »

dlrkw9mu wrote: Sat Sep 25, 2021 2:34 pm Hi,
Anyone have any experience / tips / advice on successfully appealing a health insurance claim denial?

My wife gave birth in late April, and shortly thereafter added our daughter to her (BCBS) health insurance plan through her employer. I have a separate (Cigna) plan, for just me, through my employer. I did not add our daughter to my plan, and we did not purchase any other health insurance coverage for our daughter.

In August, we received a letter from "The Rawlings Company" stating that BCBS identified other primary health insurance for our daughter, and if we are contacted by one of our health providers, to have them bill that other insurance policy as "primary". They say that the other plan identified was a Cigna plan, but give no further details. We responded to the Rawlings Company in late August stating that our daughter is not covered by any other insurance plan to our knowledge, and have not received any further communication from them.

This month we began receiving bills from our pediatrician, hospitals, etc for care provided to our daughter during April and May, with notes that the insurance company has denied the claims. We pulled up and reviewed the EOBs from BCBS for the denied claims, which state "We cannot process these charges until your other insurance plan processes them. We need a copy of their explanation of benefits (EOB) showing what they paid. Please refer to the coordination of benefits section of your benefit booklet for specific details".

We obviously plan to file an appeal, but I'm a little bit confused as to how I go about providing evidence to BCBS that no other insurance exists for her? I can probably show that she's not covered by MY Cigna insurance plan, but that really doesn't show that she doesn't have any other coverage. Any ideas? Is there a way to look up health insurance plans by SSN in the US?
This might be biting you: https://www.verywellhealth.com/health-i ... le-5114133

It can be a real mess if the earlier person's insurance is not as good.
Topic Author
dlrkw9mu
Posts: 75
Joined: Mon Apr 27, 2015 12:01 pm

Re: Proving a health insurance policy doesn't exist?

Post by dlrkw9mu »

runninginvestor wrote: Sat Sep 25, 2021 3:20 pm
Does this apply for some of the services?

https://www.insure.com/amp/health-insur ... -rule.html

Here's another article :
https://www.npr.org/sections/health-sho ... dical-bill
exodusNH wrote: Sat Sep 25, 2021 4:35 pm
This might be biting you: https://www.verywellhealth.com/health-i ... le-5114133

It can be a real mess if the earlier person's insurance is not as good.
Thanks guys... I think this is what's going on... I had no idea... what a mess.
PaunchyPirate
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Re: Proving a health insurance policy doesn't exist?

Post by PaunchyPirate »

How does this work if, before children, each parent is signed up for employee-only coverage from their respective employers. If both those companies charge the employee for “family coverage”, it would seem that when a baby is born, it would make sense to switch to family coverage using the lowest cost or best coverage plan. My former employer charged for family member coverage. So if the mother added the baby to her insurance for this reason, it would seem that the baby is not “covered” by more than one insurance, which these linked articles seem to be based on. The baby is only covered by the plan where family coverage has been added.

To the OP, if this type of situation applies, perhaps it is as simple as notifying the proper insurance company using some type of legal notice form that they supply.

If both insurance companies would automatically cover the child, then I can see how the birthday rule would apply.
runninginvestor
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Re: Proving a health insurance policy doesn't exist?

Post by runninginvestor »

PaunchyPirate wrote: Sat Sep 25, 2021 7:18 pm How does this work if, before children, each parent is signed up for employee-only coverage from their respective employers. If both those companies charge the employee for “family coverage”, it would seem that when a baby is born, it would make sense to switch to family coverage using the lowest cost or best coverage plan. My former employer charged for family member coverage. So if the mother added the baby to her insurance for this reason, it would seem that the baby is not “covered” by more than one insurance, which these linked articles seem to be based on. The baby is only covered by the plan where family coverage has been added.

To the OP, if this type of situation applies, perhaps it is as simple as notifying the proper insurance company using some type of legal notice form that they supply.

If both insurance companies would automatically cover the child, then I can see how the birthday rule would apply.
It really depends on the EOC document and their Coordination of Benefits policy. Some plans will automatically cover a newborn/dependent for the first XX number of days. Which is where this usually comes into play, and I would guess happened in the article.

I'd also add, it could very well be a mistake but just pointing out something to look into with the OP.

Annoyingly, BCBS is using an outside company for this. Probably because it's profitable for them to do so. But more difficult for the OP to sort out.
exodusNH
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Re: Proving a health insurance policy doesn't exist?

Post by exodusNH »

exodusNH wrote: Sat Sep 25, 2021 4:35 pm
dlrkw9mu wrote: Sat Sep 25, 2021 2:34 pm Hi,
Anyone have any experience / tips / advice on successfully appealing a health insurance claim denial?

My wife gave birth in late April, and shortly thereafter added our daughter to her (BCBS) health insurance plan through her employer. I have a separate (Cigna) plan, for just me, through my employer. I did not add our daughter to my plan, and we did not purchase any other health insurance coverage for our daughter.

In August, we received a letter from "The Rawlings Company" stating that BCBS identified other primary health insurance for our daughter, and if we are contacted by one of our health providers, to have them bill that other insurance policy as "primary". They say that the other plan identified was a Cigna plan, but give no further details. We responded to the Rawlings Company in late August stating that our daughter is not covered by any other insurance plan to our knowledge, and have not received any further communication from them.

This month we began receiving bills from our pediatrician, hospitals, etc for care provided to our daughter during April and May, with notes that the insurance company has denied the claims. We pulled up and reviewed the EOBs from BCBS for the denied claims, which state "We cannot process these charges until your other insurance plan processes them. We need a copy of their explanation of benefits (EOB) showing what they paid. Please refer to the coordination of benefits section of your benefit booklet for specific details".

We obviously plan to file an appeal, but I'm a little bit confused as to how I go about providing evidence to BCBS that no other insurance exists for her? I can probably show that she's not covered by MY Cigna insurance plan, but that really doesn't show that she doesn't have any other coverage. Any ideas? Is there a way to look up health insurance plans by SSN in the US?
This might be biting you: https://www.verywellhealth.com/health-i ... le-5114133

It can be a real mess if the earlier person's insurance is not as good.
I'm glad you've figured out the mystery, but I'm sorry you're dealing with this. I have no idea how the average person is supposed to know this stuff. I had just happened to have read about this some time in the recent past.

This isn't meant to be snarky: I wish you the best of luck navigating this.
toofache32
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Re: Proving a health insurance policy doesn't exist?

Post by toofache32 »

ResearchMed wrote: Sat Sep 25, 2021 3:04 pm

And then... Contact the Insurance Commissioner's Office in your state. They'll cut to the chase.
Unless this is a self-funded plan, in which case state agencies have no jurisdiction.
musicmom
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Re: Proving a health insurance policy doesn't exist?

Post by musicmom »

The birthday rule.
It applies in our state, not sure in all.

Certainly nothing that the insurance companies or employers go out of their way to explain to new parents.
exodusNH
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Re: Proving a health insurance policy doesn't exist?

Post by exodusNH »

musicmom wrote: Sat Sep 25, 2021 10:39 pm The birthday rule.
It applies in our state, not sure in all.

Certainly nothing that the insurance companies or employers go out of their way to explain to new parents.
I wouldn't blame the employers here. It's more systemic.
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Artful Dodger
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Re: Proving a health insurance policy doesn't exist?

Post by Artful Dodger »

dlrkw9mu wrote: Sat Sep 25, 2021 6:53 pm
runninginvestor wrote: Sat Sep 25, 2021 3:20 pm
Does this apply for some of the services?

https://www.insure.com/amp/health-insur ... -rule.html

Here's another article :
https://www.npr.org/sections/health-sho ... dical-bill
exodusNH wrote: Sat Sep 25, 2021 4:35 pm
This might be biting you: https://www.verywellhealth.com/health-i ... le-5114133

It can be a real mess if the earlier person's insurance is not as good.
Thanks guys... I think this is what's going on... I had no idea... what a mess.
The birthday rule has been around for 30 plus years, but only applies when both parents have family coverage, which you don’t. I’d do what’s recommend above. Call BCBS and let them know you don’t have family coverage. They’ll either update their file, or send you a form to complete and return. It happens every day.
Big Dog
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Re: Proving a health insurance policy doesn't exist?

Post by Big Dog »

PaunchyPirate wrote: Sat Sep 25, 2021 7:18 pm How does this work if, before children, each parent is signed up for employee-only coverage from their respective employers. If both those companies charge the employee for “family coverage”, it would seem that when a baby is born, it would make sense to switch to family coverage using the lowest cost or best coverage plan. My former employer charged for family member coverage. So if the mother added the baby to her insurance for this reason, it would seem that the baby is not “covered” by more than one insurance, which these linked articles seem to be based on. The baby is only covered by the plan where family coverage has been added.

To the OP, if this type of situation applies, perhaps it is as simple as notifying the proper insurance company using some type of legal notice form that they supply.

If both insurance companies would automatically cover the child, then I can see how the birthday rule would apply.
The birthday rule, which is an insurance convention, only comes into when both parents have dependent coverage. Otherwise, both parents only have self (individual) coverage, by insurance convention, the mother's policy covers the birth of the baby.

(I didn't mention the birthday rule earlier, as its not relevant in this case.)

BCBS just wants to make sure that there is no other coverage before they pay out. Standard practice. NBD.
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