Can I appeal this claim denial based on the fact customer service is incompetent and it shouldn’t have been a problem to begin with?
**TL;DR Insurance denied claim saying my membership wasn't active at the time of service, which isn't true. Couldn't appeal the denial because insurance didn't have any evidence of the claim or denial in their system. Billing office originally refused to resubmit the claim. Wrestled with insurance for 4 months just to get the claim resubmitted. Now insurance has denied the claim because it's been too much time since the date of service.**
**Do I have any hope of successfully appealing this?**
I saw a provider on 7/13/21 and then sometime in 2022 I noticed the bill in mail, called the billing office, I can't remember the exact details but I ended the call believing they hadn't billed it properly and the issue was resolved. Something about having incorrect or incomplete insurance info on file. The receptionist was argumentative but changed her tune when she realized they DID have my insurance info on file (and it was accurate?). I have a medicare advantage plan and for secondary I have medicaid.
At the end of 2022, I notice the bill in the mail again, and during this call I am told something about how the insurance (medicare advantage plan) denied it because my membership wasn't active at the time of service. But my membership became active on 8/01/21. They REFUSED to resubmit the claim.
Since january, I've called insurance atleast 10 times over this and every time they would tell me there is NO evidence of the claim in their system, even the denial. So I couldn't even appeal it. It took 4 months just to get this claim resubmitted because the customer service reps at my insurance are very poorly trained and kept giving me inaccurate info or not following up with me (one time was told to wait 45 days to check the status, called 3 times during that period to check, all to find out the claim had never even been resubmitted).
So I FINALLY got the billing office to resubmit the claim to my insurance. Insurance has denied it because so much time has passed, not surprising. So now I can appeal it.
And yes I did try to ask the billing office & the insurance rep about getting the "bill info" from the clinic and submitting it to insurance myself, both the office and insurance reps were really unhelpful with that and left me with the impression it wasn't an option.
I'm planning to call the billing office soon and ask if they can print off all information regarding this claim, the denial, etc. I know it was denied sometime around 6/22 and it's documented the reason being for my membership not being active at the time of service, which isn't true.
Any advice would be appreciated.
submitted by /u/crankytowel
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