Is their anyone that works for a medical insurance company that can answer my question?

Question

i am doing ivf, and i didn't need to be preapproved. im almost to my retreival date and i got this letter from the insurance company, can anyone tell me what this means? thanks. this is a bill for a med procedure part of the ivf. its not from the dr office, its from the insurance company. this is what it says. "our records do not reflect an authorization on file and additional info is needed from the provider to review the claim for medical necessity. if applicable submit facility records, office notes, history and physical, diagnostic reports, operative reports/anastesia records or photos for potential cosmetic procedures. after the info has been received, the claim will be processed in accordance with the plans benefit provisions." this is a bill from when i had the "trial transfer". what do u think?

Answer 1

what's a "trial transfer" ?

I do work in insurance. That letter means you DO need pre-approval.

Answer 2

IVF is only covered after unsuccessfully trying for a year to conceive the normal way.  The doctor needs to submit documentation that this IVF is really due to infertility and not for some other reason.

Answer 3

I WORK FOR A HEALTH INSURANCE FROM BLUE CROSS CA. BEFORE. Let me try and help.

This letter means that the procedure that you are having requires authorization but the provider wasn't able to get one. So instead of getting an auth. the insurance is asking for COMPLETE MEDICAL RECORDS from the hospital, as in all the records. This is becuase the diagnosis that they put up in the claim says so. there is a code or suspend/deny on the diagnosis that requires medical records for medical necessity.They will never process the claim if they havent recieve any records or if there is lacking information. For this one, disclaimer applies that this is not a guarantee for payment. They may deny the claim once it was reviewed as not medically necessary. So that only thing that you can do is send an appeal .But talk to the hospital and ask for medical records and call the member services if the records has been recieved or not and what else are needed.

If you have futher question. Let me know. I work for the claims department.

Answer 4

I think, they're saying this isn't covered yet.  Which means, it might not be covered at all.

You need to have your doctor get the authorization.

Answer 5

I am not part of a medical insurance company, but I do know quite a bit about issues of this sort, as I have heard story after story of people fighting with their insurance company because they get denied coverages they thought they had, or whatever it may be.

That being said, looks to me like the insurance company is trying to find a way NOT to pay the claim on what you had done. If this happens, and they do not pay out, then the bill will be your responsibility. It's awful, but it happens everyday to so many.

They have people specifically hired and paid to go through your personal health history file trying to find ways to deny a claim and possibly make it a pre-existing condition of sorts, or find the littlest mix up on your application that will appear as if you lied, which then means that they do not have to pay and deny you coverage.

Essentially, insurance companies are in the business of making money, not spending it. And they will do all that they can to keep it that way.

Hopefully everything will work out just fine for you!

Good Luck!