This happened to me several years ago. I called a provider and asked if they were members of "X' insurance network. They said yes. I did not call my insurance company, figuring that certainly the doctors office would know if they were members or not.
To my surprise, the insurance company rejected the claim, plus the claims of everyone that doctor referred me to for testing (even though those were ALL in network). They said the provider had merely APPLIED to be a member of "X" insurance network, and had not been approved yet. Thus that doctor, and every one he referred me to for furthur testing was denied based on the fact that he was not in network and I shouldn't have seen him in the first place.
When I called the doctors office, they admitted he was "pending approval" but stated that they assumed they could treat members of "X" insurance company anyway, and that "when he got approved" the insurance company would retro the claims and pay. This was absolutely NOT true, according to the insurance company.
I had to go through 2 levels of appeals, stating that the doctor gave me the same care, testing, and referrals that an in network doctor would have, and that all the referrals were done in network, just as if an in network doctor would have ordered. The doctors office, not surprisingly refused to give me a statement acknowledging that they incorrectly informed me in the first place. I just gave my statement of what I had been told.
On the second level of appeal, the insurance company went ahead and approved it, being sure I understood that no furthur visits to that doctor would be covered until he was in network officially.
Appeal, appeal, appeal. They hope you'll cave in at first. Stick to your guns and keep going.
Dear utahman,
If your Pediatrician is willing to accept negotiated rates for all visits from this Carrier, you may be able to work through this conflict.
Your Carrier may be able to consider your first visit out-of-network, but you can argue that the following visits were made based on their customer service agent's advice that this provider was an in-network provider. You need to call the CS again and ask to speak with a supervisor & make sure your call was documented. Most companies either record calls or make a written note in your account, documenting the interaction. Once it is established that their representative has advised you incorrectly, they will be more willing to settle.
Sincerely,
Amir Mostafaie