Claim Processing Order

Insurance is Aetna. I apologize this may be a bit ranty but I'm just very confused. I basically had a large hospital bill that resulted in me hitting my out of pocket max. In the weeks and months after I also had several outpatient appointments to manage/follow up on things. I expected those appointments to be completely covered due to having hit the out of pocket max from the hospital expenses. However that wasn't the case. In talking with my insurance I was told that "claims are processed in the order they are received." So in my case I guess what happened is that certain outpatient claims with dates of service that were post-hospitalization were received (and therefore processed) by Aetna before certain big ticket claims from my hospitalization.

I don't know if I'm crazy, but this makes no intuitive sense to me. Why wouldn't you base when a deductible or OOP max is hit on the dates of service? The date of service is always going to be consistent whereas the date a claim is sent or processed can be variable (not to mention situations when claims get reprocessed due to errors). Having it based on the date of service just makes so much more sense to me but maybe there's just something I'm missing or don't understand.

submitted by /u/FuturePhrase2930
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