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claims process with HCCMIS Hi , thanks insubuy for creating this forum. This is very insightful - unfortunately I had not read this forum until I bought Atlas America insurance - otherwise I could have purchased it through insubuy. Having said that- this is regarding a claim for my FIL who was visiting us . He is 63 years- known hypertensive with a history of COPD. He had severe chest pain and was taken to emergency and was in the hospital for three days. Various test were performed including angiogram. At the end everything was normal and he was discharged. The insurance was charged more than 50k for the admission. I understand from the beginning the pre certification requirement. Hence I made numerous calls to HCCMIS , made the hospital call and got the authorization code. Now after 45 days they get back saying pre certification is incomplete without the clinical packet which the hospital utilization department had to send. Now I contact the UR and they did send the packet but to a wrong fax number. I did request them to send it to the right number. So is there a way to make hccmis understand that as a patient I had done all that is required. I had no idea on this clinical packet. Although I got the authorization code - will I be penalized for what the hospital did not do ? How can this claim process be more efficient . Any help and guidance will be appreciated . Thanks
I am sorry to hear that you are having difficulties with your claim. As you didn't buy from Insubuy, we are legally not allowed to interfere in this matter. If you had bought through us, we would definitely help you personally. Read /why-purchase-from-insubuy/ Why buy from Insubuy. In any case, I would be glad to provide you with general help. I suggest that you contact the hospital and have them write a letter explaining what happened. If they can provide a proof that they had sent it to a wrong fax number (may be fax transmission report or something), you can attach that. After that, you can follow up with HCCMIS and explain basically what you are explaining here that you did everything you could as a layman customer. You would have no idea about this clinical packet. I don't see any mention of that patient responsibility anywhere in the certificate wording. I hope this suggestion is helpful to you and it works out for you.
Thanks so much for the reply and suggestion
Even though it is a little late, I got the following reply from HCCMIS. "Clinical packet is what we send to the provider to be completed as part of the pre certification process. It is basically the precert forms where provider fills in needed info for imas to review for med necessity. After reading the thread please advise no penalty will be assessed due to a delay of the needed information. Assure our valued member I will personally notate his file as such and follow up with our pre certification department asap. This is not an approval for payment. The decision for payment will be made after we receive and review all necessary documentation." Therefore, according to the above, you should not be penalized. Please let me know how it goes. If you need to get in touch with the person who sent me the above reply, please contact me privately.
Hi thanks so much for following up. I would appreciate if you could provide me the details of the person you contacted at HCCMIS . My email is ashu9_in@yahoo.com At present my claims is in ' in processing' stage. I have not yet received a final explanation of benefits. Thanks so much for following up. Hopefully this thread and informations will be useful I future for other customers as well .
I have emailed you the details.
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DISCLAIMER: Information presented in our Questions and Answers section is generic and was deemed to be accurate at the time of response. Please use the answers as a guide and do not make decisions based on the answers. The answers presented may be outdated and altogether inaccurate currently or not relevant as the details provided such as the insurance terms and conditions, plan benefits, eligibility and coverage may have changed. Insubuy assumes no responsibility for relying on such answers. You should review the latest certificate wording of the insurance policy (available on this website) for the product you are considering for the latest and complete details. If there is any conflict between the answers provided here and the certificate wording, the details of the certificate wording will prevail.
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