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Returned claim

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Old 02-26-2012, 02:50 PM   #1
Join Date: Nov 2011
Posts: 7
Alguy HB User
Returned claim

Hi guys,

About a month ago, I got my MRI done for TMJ. At the time of the visit, the radiologist office said I owed nothing, as my insurance company covered the entire cost. A few days ago, I recieved a letter from my insurance company claiming that the MRI is in fact not covered by the insurance since it's TMJ related. Who's at fault? It's going to cost me more than a thousand dollar that I don't have. Please help..

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Old 02-26-2012, 05:52 PM   #2
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Join Date: May 2006
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Re: Returned claim

Many insurance companies, both medical and dental, don't cover TMJ stuff at all.

I went through pretty much the same thing as you.

When I went for my MRI, I expected to be paying for my MRI. My insurance covered up to $1000 for diagnostic only, but at the time, I hadn't met my deductible at all.

When they called me to schedule the MRI, I asked them about the insurance. They told me my insurance had approved things and I didn't owe anything. When they called to confirm my appointment, I asked them about the insurance again and they re-ran the approval and told me everything was good. When I arrived for my MRI, they told me it was covered. A week or 2 later, I received my bill for around $900. I happened to have my appointment with my TMJ Specialist the next morning and I mentioned it to them. While I was with the dentist, the office manager at his office called the Diagnostic center. They confirmed things with her as well and said they would be in contact with the insurance about it. A week later I got a letter from insurance telling me they would cover the cost since they made a mistake, but shame on me for allowing them to do so. They also said not to let it happen again.

Do you have the book or an internet link to look up what your insurance covers? Most of the time the TMJ stuff is under exclusions, but now for everyone.

I'd recommend calling the radiology place to talk to them about this. They should have record of their insurance company approval.

Based upon what they tell you, you will then need to contact the insurance company. You can go from there.

Good luck,
Asthma, Allergies, Dry Eye, severe LPR/GERD, TMJD, Hearing Loss, Ulnar Impaction Syndrome, Shoulder Impingement, Ankle ligament repair, arthritis, Joint Hypermobility Spectrum Disorder

Old 03-11-2012, 01:21 PM   #3
Join Date: May 2011
Location: Tampa, Fl, USA
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Re: Returned claim

As MountainReader said, my insurance covers absolutely NOTHING TMJ-related. I believe this is a very common thing with insurances, to exclude the TMJ (not sure why). Anyway, if I were you I would have obtained the complete explanation of benefits and look it up. If it's there, not much you can do, sorry :-( What you can do thought, is explain your situation to the place that did your MRI and ask for a cash price. They usually give like 30% discount to self-pay patients. You can also set up a payment plan with them, many places do that. Pay with installments you can afford... Sorry to hear about that, it's definitely frustrating.

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