Medical vs Behavioral Health Insurance

Dio

Does anyone else have health insurance handled separately by medical vs behavioral? And it's only an issue because my providers don't belong to an in-network insurance. Anyhow, after behavioral denied my claim for initial psychological evaluation and subsequent therapy consultation with a diagnosis of "Degenerative disease of nervous system," I spent an hour on the phone with medical, and it seemed my claim was resolved to be reimbursed by medical, I get a call back from them stating that behavioral health side should be the one responsible. Good grief! 

I understand that there's a fine line when it comes to neuropsychology healthcare, but navigating through this maze is such a pain. Hopefully once resolved I can move forward with ease.

Joydean

Don’t you just love insurance! Sometimes you just want to say well which pocket did you put my monthly payment into? Sorry I get a little frustrated with insurance at times. I’m glad Dh is covered by VA and I have to deal with what department covers what. I do hope they get it straight for you. One thing you shouldn’t have to spend so much valuable time on. Best of luck to you.

Jo C.

You do not mention the insurance, so we do not have specifics; but many insurances will not reimburse for out of network providers; but there are others that will cover out of network at a lesser amount; but the differences between policies, especially with HMOs can be an issue. 

Sometimes, if an insurance will cover a lesser amount with an out of network provider but deny a claim, it is beause the billing has not been "coded" properly.  Coding is everything with billing. If that is the issue, the bill can be resumbitted with a change in the billing code that will provide coverage.

J.

Dio

Jo, that is precisely what both sides are saying, literally the same thing, that the code is not covered by them. Well, one of them should be covering it. The Dx code is G31.9 Degenerative Disease of the Nervous System, Unspecified. Since the doctors DH are seeing isn't "in-network" we do pay a higher portion. I spoke to an insurance rep from the medical side (Anthem BlueX) who is attempting to open an appeal with the behavioral insurance (Beacon Health Options). We'll see how this goes. An alternative may be to have DH's doctor change the code to a less "on the fence" Dx code? I don't know. It is definitely a headache I can do without. 

DH doesn't qualify for Medicare yet and we unfortunately don't qualify for Medicaid. 

Dio

Update: It turns out that the Dx code was deemed the problem. Anyhow, our doctor changed it to a more acceptable one by behavioral, so at least it's going through now.