I am a male who is 51 years old and a father of three teenagers.
I went through a preventive Colonoscopy and Endoscopy after my gastro-enterologist discussed over the phone the procedure with the assigned doctor from Coventry, my insurance provider, prior to the procedure being performed.
Now, Coventry is denying the claim. They are not complying with the Affordable Care Act. The reason I went through the procedure because of their approval and because of the information on the Affordable Act. If they did not approve it, I would not have done it.
Do you have any resources that I can use to demonstrate to Coventry (or any insurance provider) that this is incorrect?
Preventive services are covered under the ACA, but there are a few important things to understand about how preventive services work.
- First, the preventive service needs to be billed and coded correctly. The doctor must code it as a preventive treatment / benefit.
- Secondly, in an HMO you may need approval (looks like you got that here).
- Thirdly, things related to the preventive visit or treatment may not be covered (like a drug you need to take before the visit)
- Fourthly, if you go in to get treatment for a preexisting condition it may not be counted as a preventive treatment.
- Lastly, you can always appeal, ask the insurer, and have the doctor recode. Often the denial will have a reasonable explanation or be able to be recoded. Also if your insurer approved the treatment they may cover it based on that alone.
If you can't find an acceptable resolution you can file both an internal and external appeal. Learn more bout appeals.
Learn more about preventive services and how they work.
Also, perhaps it's just a coincidence but almost every "letter" we get about denied preventive claims is related to gastro? Is something going on here we are missing. Feel free to chime in below if you are reading this.