Question
What is the name of your state?What is the name of your state?I have Horizon HMO of NEW JERSEY. Before that I had insurance (a different company) through my university. I have no medical history. That insurance ended in Aug. '04, when I graduated. And I got my current insurance at the beginning of '05. I have paid all my premiums. In February I was diagnosed with Ulcerative Colitis. My first visit with my GI doctor was 2/3/05. I have had many visits since then, some tests, and a week hospital stay. I have sent my insurance company all the documentation requested and yet every time I ask them when they are going to pay my claims, they say that the claims are still in review. My doctor has told me that, if not paid soon (it has been four months since the first claim), he is going to send a collection agency after me. He has had many problems with this company and is considering dropping them.
My questions:
1. Is there a time limit (internal policy or law, state or federal) in which my insurance company must either pay or deny a claim? It seems that they are intent to review these claims indefinitely so as to avoid payment. I have no medical history and have submitted in a timely fashion all requested documentation, so I am not sure what they are reviewing.
2. Is there a time limit on my behalf in which I must file paperwork or take some action to complain?
3. Am I at the point where I need a lawyer? I have been told by my doctor that if I do not put pressure on them they will not pay the claims.
Any advice (although for educational purposes only) is appreciated.
Answer
Unless your state specifically has such a law (I've never had employees in your state) no, there is no time period under which they are required to either pay or deny. Obviously there is some piece of information missing that they have been unable to acquire, that makes a difference to the payment of your claims.
I strongly suggest that you CAREFULLY review all the paperwork you have received from them including EOB's (Explanation of Benefits). I cannot tell you how many times I have had people call me to demand to know why their claim had been denied, and when I looked, the EOB stated something like: "This claim cannot be paid until we receive..." and they stopped reading after the word, paid.
If there is nothing in anything you have received that says they are waiting for additional information either from you or the doctor, then call them and ask them what you can do to speed the claim along. Get them to be specific about what is still being reviewed. Then follow up with whatever they suggest.
If you STILL don't get anywhere, if your insurance is through your employer get your HR or benefits person involved. They often have contacts and accesses that you do not have available to you. Or contact your insurance broker - the same goes for them.
Finally, if none of that does any good, go over the heads of the claims people. There will be someone in a position like I used to have in the Sales office, or you can ask to speak to managers and supervisors. If all else fails, contact your state insurance department and ask for assistance.
Answer
I've dealt w/BCBS of New Jersey before. It wasn't pretty. Your claim could be "in review" for years. Literally. Go to this website and file a complaint right away...
How far you get with the dept of banking and insurance is anybody's guess, as they offered me no help whatsoever in my case, but I wouldn't hesitate to send a complaint along with a copy of the complaint to BCBS.
In Texas, we have laws that prevent this type of practice, especially for HMO's. The claim must be paid within a certain period of time, even if it's under review. I don't know if NJ has such mandates, but get that complaint filed anyway.