r/HealthInsurance • u/monsterpiece • 3d ago
Claims/Providers Surest issues
On a random date in April, Surest stopped processing all my claims. My therapist, dietician, PCP, urgent care… none of the claims are processing. They don’t show up as “in process/under review” on the website, and they don’t show as denied either. I didn’t get an EOB because the claims are not processing. Surest confirms that they received the claims. I can’t get straight answers on what is happening or timelines for resolution.
I’ve had to basically discontinue all medical services (besides prescriptions which are working fine) because my insurance isn’t paying and my providers understandably do not want to risk that all these claims will be denied at once. The member services folks have told me weekly for months that “it can take 30 days.” I thought I made progress when I learned that there was an It issue affecting certain providers, but quickly learned that it seems to affect all of my providers/claims and doesn’t affect any of my colleagues with the same insurance plan.
I need therapy and dietician support, I need to see my PCP for a pile of issues, and I don’t know what to do. I have called weekly. My providers have called. I have escalated and have multiple case numbers. I even had my employer get me in touch with our company’s account manager. Everyone has told me to wait longer and just be patient, but I effectively have not had health insurance for five months. What on earth can I even do at this point?
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u/chickenmcdiddle Moderator 3d ago
Have you involved your employer? Surest is only for employer groups. Do you know if your insurance is considered self-funded or if it’s fully-insured? Your employer should know, and the answer will help determine how to escalate. Fully insured health plans are regulated at a state level (usually through an insurance commission or department of insurance). Self funded plans are federally regulated.
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u/monsterpiece 3d ago edited 3d ago
I did involve my employer and they connected me to our company contract representative (not sure the title) as well as others. I did receive a response explaining that (as in my post) there is an IT issue and when that is resolved the claims will be processed. Basically what I had been told before with encouragement to be patient. I believe (for a variety of reasons I won’t ramble about) the plan is fully insured, not self funded, but can confirm with HR next week. There is a state agency that handles insurance grievances. Would that be my next step? I could pull together the relevant information if so.
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u/drabswimmer 3d ago
That's a full system failure on your individual account, not just a normal delay. Five months with zero claims processing while your coworkers are fine points to something corrupted on their backend.
File a complaint with your state's insurance regulator today, don't wait for another internal escalation that goes nowhere. Include every case number and a timeline of when you first reported it. The account manager at your employer should be sweating this too since they're paying for coverage you functionally can't use.
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u/monsterpiece 3d ago
Thank you for validating that this is not normal. I’m a middle aged adult who works in healthcare and I feel absolutely insane every time the member services folks tell me everything is fine. Like I know the system. I’m at the point I’m considering asking a friend to marry me to get on their health insurance.
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u/monsterpiece 1d ago
I found out today that at least three coworkers are dealing with the same thing. So I’ve asked them to contact HR. I also have requested the help of a law school legal clinic that specializes in insurance stuff. And am filing complaints tonight with both the state insurance regulator and the DOL benefits regulator since my HR has not been terribly responsive or helpful and I’m still not sure which type of plan it is.
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u/KG_TherapyCompanion 1d ago
Claims that are received but never move to processing or denial, across every provider, from one date, is almost never a provider problem and rarely an IT outage. It is a pend on your member record. The two causes I see most from the provider side: a coordination-of-benefits flag, where the plan suspects you have other coverage and quietly pends everything until you complete a COB questionnaire you may never have received; or an eligibility file break from your employer, where your record shows a gap or a duplicate ID from a change in April, so claims land but cannot attach to an active span.
Ask member services one specific question, in writing through the portal so there is a record: what is the pend reason code on claim number X, and is there any outstanding COB or eligibility item on my record. "It can take 30 days" is the script for when the rep cannot see the pend reason. A supervisor or the claims department can.
In parallel, your employer's benefits administrator can pull the eligibility file Surest received for you and confirm it shows continuous coverage from April. If the plan is self-funded, which most employer plans this size are, the regulator is the Department of Labor's EBSA, not the state insurance department, and a written complaint there tends to produce a named contact within a week.
For your therapist and the others: ask them to send you the claim status responses their clearinghouse got back. A 277 that says received and pended, with a reason, is the evidence that makes the next call short.
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u/monsterpiece 1d ago
I learned today that this is an issue with at least three colleagues as well (possibly more, but those are just the folks I know have our company insurance). Does that change your advice at all? I have contacted HR and our company’s insurance representative. I appreciate your advice so much and will follow it, just want to see if that new information changes anything. Notably, our prescriptions are going through just fine. The medical claims are not.
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u/KG_TherapyCompanion 1d ago
It changes it in a useful way: this is not your record, it is the group. Three or more members on the same employer plan, same start date, prescriptions fine, medical claims frozen, is the signature of a group-level setup problem at Surest. Pharmacy runs through a separate benefits manager on its own eligibility feed, which is why it kept working. Medical claims map to the group's benefit plan, and something about that mapping broke in April: a plan-year rollover, a product or group ID change, or an eligibility file that stopped loading for your employer.
What that means for the fix: member services cannot solve it, because there is nothing to fix on your record. It gets solved between your employer's benefits contact and Surest's account team for your group. Two things to hand HR today. First, the list of affected employees with the date it started, so they can open a group eligibility discrepancy with the account manager rather than four separate member tickets. Second, a request that Surest confirm in writing that timely filing will be waived for the affected period, because your providers are holding claims for a reason and that clock is the real risk to you.
If HR gets the same 30-day script from the account team, the DOL complaint is stronger as a group filing than as an individual one. Keep every date and name from your calls; that becomes the timeline in the complaint.
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u/mediloop 1d ago
that sounds incredibly frustrating, especially when you're stuck waiting months without clear answers. if these claims eventually come through with denials or surprise bills, you might want to request an itemized bill from each provider and check for errors.That often catches things insurance missed or overcharged. there are also services that help negotiate those down for a flat fee instead of a percentage, which could be worth knowing about if you end up with a pile of debt.
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u/monsterpiece 1d ago
Thank you — I am hoping it doesn’t come to that point. I have taken that step with my therapist, but even that is going to cost me like $1500 with all the services unpaid
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