In short,
1) UHC (under contract with my insurance provider GEHA HDHP) incorrectly relayed to the provider's office that no prior authorization was required, whereas it should have stated that the provider's office contact the pharmacy benefits manager (PBM) for pre-auth.
2) My provider's office incorrectly conveyed to me that it obtained prior authorization, whereas in fact it was told no prior authorization was required.
I went ahead with the treatment at my provider (otherwise deemed in-network). Due to mistake(s) of insurance and/or provider, my treatment at the provider (otherwise in network) is now deemed uncovered by PBM, which states that other medications should have been tried first unless I develop adverse reactions to those. Not only is the injectable per se not covered, nor is the provider's charge for administering covered. The latter seems like a cheap cop-out, as regardless of which injectable is used, someone has to do the injection.
What are my options to contest this? Should I get my state's insurance regulator involved?
If all else fails, how do I negotiate down the charges?
More detailed version as follows:
After an initial visit, my provider decided on a treatment plan using an injectable, based on past success using the same injectable. My provider called the prior authorization telephone line (staffed by UHC) listed on my insurance card, and was told by UHC that no prior authorization is required for the treatment (a series of injections for my knee). The provider's office has records of this call, but when it relayed it to me, it stated that prior authorization was obtained (as opposed to no prior authorization needed). Because I was under the impression that prior authorization was obtained (as opposed to the office being told one is not needed), I went ahead with the injections.
As I'm starting a thread on this, it probably doesn't surprise anyone that this procedure is deemed incorrect by insurance. Because the injection entailed a medication, apparently the provider should have called the pharmacy benefits manager (PBM) number on my insurance card, as opposed to the line expressly listed on my insurance card as "prior authorization". The PBM has thus far denied the claims for the series of injections (saying other injectables should have been tried first), and I wonder what my recourse is.
ETA, the plan brochure is not at all clear about non-preferred drugs. It states under physician-administered drugs:
• Generic and Preferred: $300 copayment applies per prescription fill and 25% of the Plan allowance, up to a 30-day supply.
• Non-Preferred: $500 copayment applies per prescription fill and 40% of the Plan allowance, up to a 30-day supply.
Advice on this greatly appreciated.
1) UHC (under contract with my insurance provider GEHA HDHP) incorrectly relayed to the provider's office that no prior authorization was required, whereas it should have stated that the provider's office contact the pharmacy benefits manager (PBM) for pre-auth.
2) My provider's office incorrectly conveyed to me that it obtained prior authorization, whereas in fact it was told no prior authorization was required.
I went ahead with the treatment at my provider (otherwise deemed in-network). Due to mistake(s) of insurance and/or provider, my treatment at the provider (otherwise in network) is now deemed uncovered by PBM, which states that other medications should have been tried first unless I develop adverse reactions to those. Not only is the injectable per se not covered, nor is the provider's charge for administering covered. The latter seems like a cheap cop-out, as regardless of which injectable is used, someone has to do the injection.
What are my options to contest this? Should I get my state's insurance regulator involved?
If all else fails, how do I negotiate down the charges?
More detailed version as follows:
After an initial visit, my provider decided on a treatment plan using an injectable, based on past success using the same injectable. My provider called the prior authorization telephone line (staffed by UHC) listed on my insurance card, and was told by UHC that no prior authorization is required for the treatment (a series of injections for my knee). The provider's office has records of this call, but when it relayed it to me, it stated that prior authorization was obtained (as opposed to no prior authorization needed). Because I was under the impression that prior authorization was obtained (as opposed to the office being told one is not needed), I went ahead with the injections.
As I'm starting a thread on this, it probably doesn't surprise anyone that this procedure is deemed incorrect by insurance. Because the injection entailed a medication, apparently the provider should have called the pharmacy benefits manager (PBM) number on my insurance card, as opposed to the line expressly listed on my insurance card as "prior authorization". The PBM has thus far denied the claims for the series of injections (saying other injectables should have been tried first), and I wonder what my recourse is.
ETA, the plan brochure is not at all clear about non-preferred drugs. It states under physician-administered drugs:
• Generic and Preferred: $300 copayment applies per prescription fill and 25% of the Plan allowance, up to a 30-day supply.
• Non-Preferred: $500 copayment applies per prescription fill and 40% of the Plan allowance, up to a 30-day supply.
Advice on this greatly appreciated.
Statistics: Posted by InvisibleAerobar — Mon Apr 22, 2024 1:42 pm — Replies 0 — Views 82