United -Primary Federated - Secondary - ThinnerTimes

Carol Tomey · 06-09-2008, 10:49 AM

United HC, provided thru my employer, denied surgery as it is excluded in the policy. Appeal was an excercise in futility. I am now on my husband's Federated/Sagamore HC and it DOES cover WLS. I am waiting for Federated pre-certification. Does anyone know if Federated can deny coverage since United my primary HC insurance provider did deny? I am just concerned. I have yet to get a response from Federated.

Vikkator · 06-09-2008, 11:35 AM

Carol, you mentioned that you're still waiting to hear from them. Is there a number you can call to speak with someone directly? My insurance company told me right over the phone, whether or not it was covered.

Carol Tomey · 06-09-2008, 05:02 PM

Vikki - I spoke to someone at Federated and looked at the policy. It IS covered. When I got home today I received a letter from Federated that stated "Thanki you for the verification of PRIOR coverage. This coverage will be credited on your pre-existing. Your pre-existing will be in effect on 09/01/08. (I was just put on my husband's policy effective June1) I was told over the phone two weekws ago tht the pre-existing would be waived. Now I am really confused and frustrated.

frances · 06-10-2008, 05:37 AM

Quote:

Originally Posted by Carol Tomey

Vikki - I spoke to someone at Federated and looked at the policy. It IS covered. When I got home today I received a letter from Federated that stated "Thanki you for the verification of PRIOR coverage. This coverage will be credited on your pre-existing. Your pre-existing will be in effect on 09/01/08. (I was just put on my husband's policy effective June1) I was told over the phone two weekws ago tht the pre-existing would be waived. Now I am really confused and frustrated.

I think the accurate answer to this would be finding out which insurance is your primary coverage. Whose birthday is first in the calendar year? Typically a secondary insurance will only cover the copays or coinsurance amount from the primary. If something isn't covered by the primary then the secondary won't cover either - again, I said typically.

Find out which insurance is primary and then go from there.

Vikkator · 06-10-2008, 05:46 AM

Leave it to insurance companies to confuse us even more. I agree with Frances.

Carol Tomey · 06-10-2008, 09:43 AM

My husband's policy covers and I qualify for the WLS. How can they deny just because my primary carrier excludes coverage? He pays as much as he co-workers for the employee spouse coverage. The purpose in covering me on the Federated policy was to help with medical expenses not paid by United HC.

Carol Tomey · 06-10-2008, 10:59 AM

Spoke With Federated rep. She said it would be covered regardless of what United does with the claim. Now I just wait for the pre-certification from Federated. What is the average time for pre-certification?

frances · 06-10-2008, 06:46 PM

Quote:

Originally Posted by Carol Tomey

Spoke With Federated rep. She said it would be covered regardless of what United does with the claim. Now I just wait for the pre-certification from Federated. What is the average time for pre-certification?

Although, after almost 20 years in the claims business, I would make sure I have a letter that specifically states this. Insurance company reps can say anything - all that matters is what happens with the claim once it is submitted. I have had untold numbers of claims denied because once it is submitted, they have no documentation of an exception approval - so they deny.

Just been my experience with submitting over 1 billion dollars worth of claims a year.

Carol Tomey · 06-11-2008, 08:32 AM

Thank you for your reply Frances. Who and when do we ask for the letter? After pre-certification? Do I ask for the letter or does the hospital? From what you are saying the pre-certification means only you are pre-certified for the insurance company to "consider" paying for the procedures.

Thank you for your help. Carol

frances · 06-11-2008, 09:13 PM

Quote:

Originally Posted by Carol Tomey

Thank you for your reply Frances. Who and when do we ask for the letter? After pre-certification? Do I ask for the letter or does the hospital? From what you are saying the pre-certification means only you are pre-certified for the insurance company to "consider" paying for the procedures.

Thank you for your help. Carol

If they send you an auth letter or a precert letter then make SURE you keep a copy of it. That should be all you need, but you never know. Typically insurances have coordination of benefits for when they are secondary so they will pick up the copays/coinsurance/deductibles AFTER the primary pays. If they are saying they don't COB then you are allright. Just keep the letter after you get it, just in case.

As to when you should ask for one, if they send it to your doctor's office then you can have them just make you a copy. Don't stress, I just want to ensure that I give you the information that I have. Maybe between all of us on this site, you won't have to go through some of the hoops that others have had to jump through.