The State of NJ outsources the medicaid to 5 HMO insurance companies. I was billed by an ER doctor in December for an ER visit in September. I have been trying to get the EOB from Amerigroup and they refuse. I have looked at laws and the contract between the State and the HMO, and as far as I can tell, every carrier including every HMO in the State must provide the EOB within 30 days of each claim. The State says no they don't. Now I feel like my Rights are being violated. Does anyone have this problem?
N.J. Admin. Code § 11:22-1.2 - Definitions
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, a dental service corporation or dental plan organization authorized to issue dental plans in this State, and a prepaid prescription service organization.
N.J. Admin. Code § 11:22-1.16 - Explanation of benefits
(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan.
Anthem, Amerigroup's parent company has a lovely tutorial that medical professionals can use to see if they've been paid. If you Google Amerigroup EOB, you'll see it.
Why can't you print out what is shown in your online account and send that to the ER docs?
If the names are on different pages, you just print out all the pages. Or copy and paste the document into an email.
My nephew was going to a Neurologist while he was on his guardians insurance. Once on Medicaid the Neurologist did not except Medicaid. I asked if I could pay for the visit and was told no, Drs are not allowed to except payment from Medicaid recipients. When nephew was OKd for SSD, he then received Medicare and Medicaid as his secondary. The Neurologist then took him back. I notice the Medicare Statements show a balance owed the Dr. but nephew has never been billed for it.
I really think this is a billing problem. Someone has not credited your account with the doctor if u show they were paid. If it was submitted and not paid, that is not your problem. Its up to the billing clerk to find out from the insurance company why they were not paid. I have had insurance companies call a doctor for me telling them the claim was processed and paid. They have the check info. You have a Medicaid caseworker, get him/her involved. Coding is the billing clerks problem. Its the clerks job to get the doctor his money. A coding error is not uncommon. Clerk just needs to reenter the claim with the propper code.
Ask ur caseworker if I am correct about a Dr. not being able to bill you as a Medicaid recipient. A doctor excepting Medicare and Medicaid have to except what they receive from them. There is no billing the patient for money not received.
Me, I would call the billing office and tell them as a Medicaid recipient you are not responsible for any charges. If they have not been paid by Medicaid, its up to them to find out why not. And I have asked this question from my insurance provider. Do I do the research or the billing clerk and I was told the billing clerk.
I may also change providers if this Amerigroup is not willing to call the Dr and straighten this out for you. My nephew has Horizon B/C B/S and I have B/C B/S thru my husband's union and have had no problem with them helping me. Once with fraud on an employee of the doctor's.
The above link may help you navigate the NJ Medicaid system and answer some questions. Try calling Legal Aid, they may have an answer for you regarding the 'legality' of Amerigroup having to provide you with an EOB for services rendered. The laws may be different pertaining to Medicaid requirements, IDK.
Good luck.
if I recall your previous posts, you have no income or assets and are therefore judgement proof..
Consider sending a letter to the medical practice stating that Amerigroup is your insurance carrier and any billing issues will need to be taken up with them. And that have no income or assets..
Send copies of what you write to Amerigroup and the NJ State Insurance Commission.
Conside contacting your local state representative to resolve this.