Insurance Reimbursement Help

[Mommy2MCL]

Our PANDAS specialist does not take insurance, like many of them out there. We are new to this and I was wondering if their are any tried and true tips that help the reimbursement claims be processed. We have seen him 2x and once was already denied.

 

I understand that these may not be paid out but if there are things I could do to help it that would be great.

 

Thanks so much!

Megan

[pr40]

we have Harvard Pilgrim. HMO gave us quite a ride. I asked them to name one PANDAS specialist in network. finally they did pay, but our expensese were under 1k. then we had to get POS that allowed us to go out of network. that was, basically, the advice on the forum. In our experience, the higher primium of the POS plust the deductible was not worth it. others on the forum said that it was worth it for them. you may want to do reasearch of threads that are over a year old or start a new one on the kind of insurance you should have. Most insurances don't reimburse what they don't have to and that includes drs out of network.

[Mayzoo]

My best advice:

 

Download the forms for reimbursement directly from the insurance website.

 

Make sure you follow the directions to the letter.

 

Double check the ICD-9 found on your doctor's receipt to make sure it is a covered condition BEFORE you ever mail it in. You may have to call your insurance for this one. If the condition they listed is not covered, talk to the office about changing the ICD-9 to a covered one.

 

Keep copies of everything you mail in with detailed notes on it of who you spoke to, and what the date/time was.

 

If three weeks go by after you mail it in and you have not heard from your insurance company, try to make the time to call them (and keep notes again on your copy of the bill you mailed in). Continue calling every now and then to check on the progress.

 

Good luck .

[airial95]

Be aware, if you are doing phone consults, those are not covered by insurance and are not eligible for reimbursement by law in most states.

[JoyBop]

If the doc doesn't accept your insurance , unfortunately your company doesn't have to pay. But you can and should call and ask about appealing the decision. Sometimes if you have tried everyone in network and they have not met your needs you can get reimbursement if you work hard at it and are lucky. I would advise that you don't mention PANDAS. Most insurance cos will not cover any out of newborn visits for disorders that are not yet official diagnosis. I would say Something along the lines of post infectious I cephalopod or brain dysfunction not other specified.

[Mommy2MCL]

Thanks everyone! Yes the dr coded it as OCD & post encephalitis... Someone needs to write a PANDAS for Dummies... Thanks for the advice