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Old 02-24-2013, 04:19 AM   #1
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Join Date: Jun 2001
Location: Marlboro, NJ USA
Posts: 206
maglib HB User
Primary is Auto Insurance, secondary is HMO

My primary insurance is my auto insurance as my bills are related to an auto accident. The doctors got all the necesarry approvals. We were told by the doctors office that they accept our "name of co" insurance as secondary.

The primary insurance has a high deductible. OUCH! So the EOB from the primary, adjusted the bills to some approved rate and after applying the deductible coverage was $0.

The secondary insurance "the HMO" covered nothing as they are telling us 3 months after the fact that the doctors were "out of network". I understood that the primary determined which doctors and what services are covered. Irregardless I was under the impression that the doctors were in network.

First the doctor told us they accepted our insurance and reality was they took the PPO. The doctors office never told us otherwise although we gave them our insurance cards, reminded them in January to bill our HMO as secondary. They never said they didn't take the HMO and had plenty of times they should have.

I also understood that when you have 2 insurers that the PRImary determined which doctors you could see and what health benefits you could have. Then the secondary paid in accordance with approved billing that the primary held you too.

Please anyone with actual knowledge help me out here. It's close to $5k in medical bills and I stopped going for service now just because of the cost and am now getting worse.

I went to these doctors for 3 months.

An additional note is that Hurrican Sandy causes over 3 weeks of no power in the area and the only way to find out who was in network was using a phone book, hoping an office had power and wasn't backed up for months. I could not have known easily who was in network. If I checked after I could have, but since nobody said anything for 3 months that we weren't using in network I thought all was good. The HMO did cover the first visit as they did have it under SANDY related and lack of providers so they did pay 1 visit. So another argument I believe I should have is aren't I allowed to continue treatment with same providers, it would have been much more time to change doctors.?

PLEASE HELP as I need to file this appeal and trying to figure out what the RULES really are.

I'm in NJ if that means anything.

Last edited by maglib; 02-24-2013 at 04:25 AM.

 
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