:rolleyes: I had to go to the local emergency room on 1/5/06 at 2:00 a.m.
I followed up with my doctor on 1/16/06 and returned to work on 1/17/06. Blue Cross/Blue Shield is refusing to pay saying "I did not have a referral so this claim is being processed as out-of-network." You can't exactly get a referral at 2 in the morning. When I went to my doctor's office about this they said it is illegal to postdate a referral. I pay $110 per week for THIS??
It clearly states in my policy and on my insurance card that I only have to pay $35 for visits to the emergency room. Any help would be greatly appreciated, I am SOOO tired of being ripped off by these people.

I hear ya, maybe you should have called the next day about getting a referral?
I would appeal, I would always appeal any denial from BCBS or any insurance. Just explain that it was not clear to you either on your card or in your policy that you needed a referral at 2am, and how would you go about getting a referral at that time in the morning, it was an emergency

Was this an in network hospital or er? Then state that you went to a participating hosp and you thought that they would call for the referral, that might be a long shot but what do you have to lose except more $$

Good Luck
Steph

I,too, have BCBS and they must pay for the emergency room treatment. You do not have to have a referral. Call and ask to speak to a supervisor. The people that answer the phones have many mistake over the years with my husband and myself. I always get everything resolved,but insist on talking to someone who is higher up and in charge.

Thanks for your suggestions. I did call the next day about a referral and was told by my doctor's office that they could not postdate a referral. This was an in network hospital. I will try calling again (if I can finally reach a human) and ask for a supervisor. If this doesn't work, I will appeal. In the meantime, I am shopping around for other insurance. It's pretty sad when I paid them over $5,000 last year and here they don't want to pay a measly emergency room bill.

:rolleyes: I had to go to the local emergency room on 1/5/06 at 2:00 a.m.
I followed up with my doctor on 1/16/06 and returned to work on 1/17/06. Blue Cross/Blue Shield is refusing to pay saying "I did not have a referral so this claim is being processed as out-of-network." You can't exactly get a referral at 2 in the morning. When I went to my doctor's office about this they said it is illegal to postdate a referral. I pay $110 per week for THIS??
It clearly states in my policy and on my insurance card that I only have to pay $35 for visits to the emergency room. Any help would be greatly appreciated, I am SOOO tired of being ripped off by these people.


Many companies will not pay in-network benefits for the ER if the visit was not an emergency, and a referral was not obtained for the non-emergency visit. It's a crappy policy, but it's not unheard of. If you can prove that no other medical care was available to you and your condition required medical attention at that time, you should be able to appeal the out-of-network decision.

We have BCBS also and had to take DS to the ER last year when he got something in his eye after business hours. We had to pay $50 copay for the ER and $20 copay for the office call. Think the total bill (including the copays) was $175. It was an in network hospital.

I'd ask BCBS to send you a copy of the section of your policy handbook that indicates where this was denied. I once was charged because I had a "non-covered provider" for an anesthesiologist. Hello? I was unconscious at the hospital that was in network. Turns out it was a teeny tiny little typo.

And as far as getting a referral after the fact. When DS was born, he had to be lifeflighted to a major city for emergency surgery because the pediatric surgeon was on vacatino -- two to three months later we were still getting charged for going out of network. DS's primary doctor had to go to the head of the hospital, who filed paperwork giving DS a referral for the 4 weeks he was at another hospital. We didn't have a choice in the matter and kept getting the run around -- told by the clinic and BCBS it was taken care of, only to get past due bills. Finally camped out at the BCBS office and said, okay, what do we need to do. Once we found out WHO needed to submit the paperwork and got that taken care of, we were getting reimbursed by the hospital and clinics for charges we'd paid.

It's not illegal to postdate a referral, its done all the time. what would you need a referral for? the er visit? if so, that is not needed. if you followed up with a specialist and not your PCP, then you would need a referral. there is a difference between referral and authorization. a primary dr referrs you to see another dr, a specialist. an auth is when you require an approval for certain procedures-surgery, inpatient stay, and major test like MRI's. an ER visit requires auth after the visit, but usually the provider does that.
also-its not always necessary to go right to a supervisor-some of us who answer the phones are very knowledgable, you should have a copy of your current summary of benefits with you as well. I suggest you save your explanation of benefits for a year, and keep your contracts in a safe place!
good luck with the appeal.
also-most insurances cover world wide for ER or urgent care so there shouldn't be an out of network penalty!!!