Claim approval exceeds cap

Hi all,

I have anthem blue cross through my work. I did a pretty expensive imaging test on 6/22 which I had prior approval for.

My plan is structured as $2,000 deductible, then coinsurance at 20% for $1,500 for yearly out-of-pocket maximum of $3,500. At the time if service I had already paid about $2300 for the year and had several pending claims.

I received a EOB for approved claims through 7/6 which clearly my remaining OOP as $874.78. The claims for the image test was NOT included in this EOB. I have done other testing and doctor visits and have indeed paid the $2,625.22 already as shown on the EOB. So I had tons of services before my tesr/procedure l.

The imaging claim was approved on 7/7 and shows this

Billed $16,376.62 Plan discount -$492.05 Allowed by plan $15,884.57 Plan paid -$12,707.67 You owe $3,176.90

No EOB has generated for this yet. I'm trying to figure out how I owe $3,176.90 when my max OOP is $3,500 and I only had $874.78 remaining the day before this was approved.

Of course they are closed. The live chat lady was zero help, shows my 874.78 before claim approval but could not tell me how the amount due exceeded that.

Any insights? I don't get where the extra amount over 874.78 is coming from or how it's allowed.

submitted by /u/rootdet
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