NJ Aetna health ins claim denied even though agent said it’s covered on recorded line.

My daughter wanted to have extractions of impacted teeth performed at an outpatient facility. Her doctor’s office called Aetna and spoke with an Aetna representative. They asked if precertification was needed, whether the outpatient facility was covered, and if codes 7240 and 9420 would be a covered. The Aetna rep said precertification was not needed and that the outpatient facility and the codes provide would be covered 100% after deducible. Based upon the Aetna agent’s representation of coverage the extraction surgery was performed. But when this claim was processed by Aetna it was denied because my plan doesn't cover this service.

I have made one appeal that was denied and I about to submit my second and final appeal. Prior to my first appeal, I asked that the recorded conversation between the Aetna representative and her doctor’s office be reviewed. I was basically told that the Aetna agent made a false representation of coverage but being as my coverage with Aetna is though my employer as self-insurance coverage, they could not make an exception and pay the claim.

Any thought on:

The likelihood of winning this appeal?

If I should file a complaint with the state of NJ before/after filing the second appeal?

When to get my HR department involved?

submitted by /u/flew-d-coop
[comments]