Aetna stating referral for hospital itself was needed for surgery
Hello. I need some advice. Wife had a surgery done last month by her gynecologist. We made sure she had a referral on file which we had gotten previously. I verified all the cpt and dx codes with the doctors office and contacted Aetna to make sure no pre authorization was needed and everything was square with the specialist referral. We both actually checked multiple times with multiple people seeing we knew this was going to be a pricey outpatient surgery. I was assured by Aetna customer service agent everything was good. And of course a few weeks ago I see in my EOB that the 60k bill is denied. I ask Aetna why and originally they tell me it was a billing error but a week later they tell me it was because we didn’t get a referral for the hospital itself! The hospital itself is in network though and I ask where in my plan documents this is listed that I need a separate referral. Of course they cannot find it in my docs but only in their internal docs. Anyways I put it for an expedited appeal and it comes back being denied for the same reason. Nobody can explain to me why over the 30 times we’ve called there wasn’t a mention of a hospital needing referral for the surgery. This all sounds like bs to me. Any thoughts? I’m planning to contact my hr dept and also file a complaint with the dept of insurance in my state.
submitted by /u/aznbbalplaya
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