TPA plan says one thing, pricing insurer says another

Throwaway account for reasons

I work as a medical billing A/R specialist for an ear nose and throat office. Audiologist give patients hearing aids all the time and verify a patients benefits before they are given to the patient. Patient came in, her benefit booklet says hearing aids are covered 100% with no deductible or coinsurance. Limit to one pair every three years. Patient has never had hearing aids before so this is fine.

Back of the patients card says to submit all medical claims to Cigna, as they price the claims. I suppose the actual insurance and benefit booklet are from a small TPA. Don't recall if the plan is self funded or not.

Cigna denied her claim completely. Paid nothing. I called both the TPA and Cigna and asked for an explanation. They both pointed the finger to the other party.

I want to know what, if any, are my options here for getting this claim paid. I submitted an appeal with the TPA and they denied it stating that Cigna priced the claim correctly. Maybe I need to report it with the department of insurance? Advise appreciated!

submitted by /u/HearingAidThrowaways
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