Does Horizon BCBS flip a coin when deciding to cover claims?

I live in New Jersey and have Horizon Blue Cross Blue Shield health insurance. I started seeing an out-of-network therapist in 2023. Once I met my out-of-network deductible ($300), Horizon automatically reimbursed me 70% of my claims for this provider. However, I once waited four months to file my claims for therapy. Once I sent Horizon that large bill, it was completely denied.

Suddenly, Horizon said in its explanation of benefits that it could not verify my therapist's NPI, license, tax ID number, or W9. My therapist does not deal with insurance, so she provided me with her NPI and tax ID number (the NPI and tax ID numbers are also on the superbills that I submit to Horizon). She does not have a W9 form because she is the sole proprietor of her business. I called Horizon to give them these numbers, but they refused to accept them over the phone. A representative told me to re-submit the claims with this information. I did that, and again it was denied for the same reason.

I filed an appeal and sent Horizon a letter explaining the situation, all the superbills I submitted, the claim number, dates of services, my therapist's NPI and tax ID number, a copy of her active license through the NJ Dept. of Consumer Affairs website, etc. I also explained that she does not have a W9 form because she is the sole proprietor of her business. I got tracking on the appeal I sent through the mail and it was received in Horizon's Newark office about two days later.

Horizon never officially responded to my appeal. I used Horzion's email tool on the website to inquire about the status of my appeal about 60 days after it was received. I was told that Horizon sent my therapist a letter asking for her NPI and tax ID, but my therapist said she never received it. When I called Horizon to ask them about this letter, two different representatives told me that my appeal was still in review and that I should not have received an email with information about it. Horizon, according to the reps, only replies to appeals through snail mail.

After about eight hours on the phone over the course of several days, I got in touch with a supervisor who profusely apologized to me. She said that Horizon should have put my therapist's information into their system, but hasn't. She approved my claim and also gave me her work email to help me with future claims with this provider.

In the meantime, Horizon was approving claims for this same provider in 2024. However, Horizon denied another claim from 2024 for this same provider even after I met my out-of-network deductible for 2024. When I called Horizon to ask about this claim, I was told that my therapist needs to submit her information on this website: https://providerenrollment.horizonblue.com/?root_id=3b9e6b67984c39d820629bda00ba1ddd

A senior rep also told me that if the state audits my account, I will have to reimburse Horizon for all of the claims it approved for therapy because Horizon does not have my provider's information. I emailed the supervisor who approved my claim that was in appeal to ask for help, but she never responded.

My therapist has also called Horizon through the provider line several times and has given her information. Specifically, they told her they couldn't verify her w9 form. However, she does not have a w9 because she is the sole proprietor of her business. A representative told her to download a W9 form online and just fill it out and upload it, otherwise they won't verify her information.

(Side note: I finally stopped going to therapy partly because I can't continue to deal with this stress from Horizon.)

Why is it that sometimes Horizon automatically approves these claims from my therapists, and other times does not? Why does an out-of-network therapist have to send their information to Horizon? I've never heard of Horizon requiring a therapist to do this. Why can't Horizon verify my therapist's license and tax information on its own? Why hasn't Horizon officially responded to my appeal? Has anyone ever had to reimburse Horizon for claims it already approved? Thanks, I'm in a bureaucratic nightmare.

submitted by /u/Gucci_Piggy
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