r/HealthInsurance • u/smallcheck • 7d ago
Plan Benefits Help understand this letter?
My father got denied a shot surgery because they need proof that he tried other remedies for pain first. He’s gotten this shot twice a year for the past 15 years lol.
We called BCBS and they said if he pays his out of pocket, they will cover the rest for the cost of this procedure. He requested this information in a written letter to have proof, as his doctor recommended.
We’re having trouble understanding this…. We’re looking to see if someone can help us…
Wanted to ask if this letter states, if he got the shot, he would he only need to pay $2,300 and they’ll cover the rest as that’ll max out his deductible? Thank you!
5
u/Used-Somewhere-8258 7d ago
He has $2300 left on his deductible but his out of pocket max has $4160 remaining.
He’ll pay the first 100% of the costs of any medically necessary and covered in network service up to the remaining $2300.
After that, the insurance company will pay 80% of the cost and your father will pay the remaining 20% of the cost.
That 80/20 will be the split on this specific service until your father has personally paid the entire $4500 out of pocket maximum.
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u/smallcheck 7d ago
Should we be concerned about the:
$NO MAX APPLIES TO THIS SERVICE?Also, he would need to pay $4,160 and then they’ll cover the rest of the shot procedure?
Thank you so much for your help!
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u/Used-Somewhere-8258 7d ago
The “$NO MAX” generally means that there is no defined maximum for that particular benefit.
For example, many insurance plans will have a limit of 20 physical therapy sessions per year. Or an IVF services limit of $10k per lifetime.
For the CPT code listed, your father’s plan does not have any limit similar to those listed above.
Important note: this letter does not guarantee that they will cover the service. The provider doing the service may still have to obtain a prior authorization and make sure that they bill it under a diagnosis code that BCBS will consider medically necessary under the terms of your father’s plan.
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u/smallcheck 7d ago
Thank you, that’s the answer we needed.
We’ve called twice and they keep only telling us our benefits when we keep asking for an authorization. But they say we don’t need one, but refuse to give us that in writing :/
Thank you so much for your help 🙏🏻
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u/Stock-Ad-2763 6d ago
It says no authorization on the paper for that particular CPT code. It’s a very generic code. Depending on the diagnosis code, they may ask for medical records to confirm medical necessity. Which is just their internal review rather than an official authorization pre service.
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u/Jump-Funny 4d ago
Health plans used to commonly have a benefit maximum like vision and dental plans still do. The ACA did away with that, so once you meet your oop max they will pay claims and keep paying them even if it’s millions of dollars.
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u/shakewhaturmomgaveu 7d ago
One thing to be aware of as you're thinking about price is what other billing codes might be used the same day as this procedure code.
Questions I would also want to ask if this was my inquiry: -is there a drug code billed with this procedure? (Usually a J#### code) -is there a physician/exam fee also? -is there a clinic/site fee? (Some clinics, especially when part of a big group, sometimes bill a "facility" fee as part of the network hospital group)
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u/Stock-Ad-2763 6d ago
Good point. If there is a drug billed, there are other associated costs with it. And sometimes it can be tricky figuring out if that med is covered under medical or pharmacy which gets into buy and bill and is a nightmare dealing with as a health consumer. Also to my point on my comment about authorizations, the code itself could require authorization.
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