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  1. #1
    Join Date
    Jan 2011
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    17

    Default Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    My question involves insurance law for the state of: NY

    My wife's Doctor's office had neglected to make pre-certification for the MRI and Insurance denied that claim. Now provider's billing us for that. Whose responsibility is to make pre-certification, doctor's or patient's?

    PS. Doctor's office is an in-network provider.

  2. #2
    Join Date
    Apr 2009
    Location
    Somewhere near Canada
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    35,894

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    It's the patient's responsibility to ensure procedures are covered.

  3. #3
    Join Date
    Jun 2006
    Location
    Massachusetts
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    24,521

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    This *may* be one of the rare exceptions.

    Naratino, do you have a copy of the SPD for the health plan? This is NOT the same thing as your employee handbook. If you do, I'm going to need you to type out a section WORD FOR WORD. If you don't, you need to go to your employer and ask for a copy. They are required by law to give it to you on request.

    When you have it, let me know, and I'll tell you what I need you to copy.

  4. #4
    Join Date
    Apr 2009
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    Somewhere near Canada
    Posts
    35,894

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    Apologies - I will defer to you

  5. #5
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    No problem - that would be the right answer most of the time. This is one of the few times, however, that the responsibility *may* fall on the doctor - it will depend on the EXACT wording of the policy.

  6. #6
    Join Date
    Jan 2011
    Posts
    17

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    Quote Quoting cbg
    View Post
    This *may* be one of the rare exceptions.

    Naratino, do you have a copy of the SPD for the health plan? This is NOT the same thing as your employee handbook. If you do, I'm going to need you to type out a section WORD FOR WORD. If you don't, you need to go to your employer and ask for a copy. They are required by law to give it to you on request.

    When you have it, let me know, and I'll tell you what I need you to copy.
    I've got the "Member Handbook". Will this one work?

    I found this in the Handbook
    ...Some Covered Services require Precertification. Your Summary of Benefits shows which services must be Precertified. Your PCP, Primary Provider of OB/GYN Care or Freedom Network Specialist is responsible for obtaining all Precertifications for In-Network Covered Services....

  7. #7
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    When you say Member Handbook, are you referring to an employee handbook that describes ALL benefits, or is it exclusive to the health insurance?

    If it's exclusive to the health insurance, we're good to go. If it covers all benefits, then we need the Summary of Benefits referred to above. Although the statement you've quoted does suggest that this is going to be one of the exceptions to the general rule Doggie quoted.

  8. #8
    Join Date
    Jan 2011
    Posts
    17

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    The full title is:
    Oxford Health Insurance, Inc.
    Freedom Network Direct
    Member Handbook
    And, I found the Summary of Benefits.

  9. #9
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Doctor's Office Neglected to Make Pre-Certification - Claim Denied

    That's what we want. Find the section that discusses when and how a pre-certification is needed, and type it out word for word. We'll go from there.

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