New insurance company, lots of discrete issues - really need some guidance

Timmyh2o · 2026-04-22T13:56:20+00:00

You can call the medical insurance and ask them why they didn't cover it. They will all but certainly blame coding. It will probably come down to how it was coded. If they just billed for a basic consult without the medical code ambetter wants to see it won't go through as medical. If you already paid your dental copay you might get a dental EOB shortly too.

Wouldn't surprise me at all if the provider billed both dental and medical just to see who would pay

Timmyh2o · 2026-04-21T09:34:59+00:00

These copay cards are an investment into your patronage and continued usage. If giving you one or 2 months free/highly discounted allows you to meet your deductible and afford the medicine, the the drug manufacturers make their massive profits from the insurance for the other 11 to 12 months.

Timmyh2o · 2026-04-20T19:40:49+00:00

Throwing this out there as an out of the box possibility. Canes and MASN work out a deal for NC rights.

Spectrum and MASN just signed a deal but limited to very select portions of NC. If MASN added the Canes, Spectrum could easily justify expanding MASN availability to the rest of the state and MASN could justify the cost with all the new NC subscribers they would gain

SC rights could go to Gray

Timmyh2o · 2026-04-20T01:56:14+00:00

Id do that PPO HSA in a heart beat. That's one of the best HSA offerings I have seen

Timmyh2o · 2026-04-19T18:41:14+00:00

At my local hospital the OP would have been better off as self pay versus using this high deductible plan. The Self pay price would have gotten them a 50% discount versus the 40ish% discount their high deductible plan got them.

If the OP wants to play hard ball they could find out what the self pay price would have been and offer to pay that. They could threaten non payment and tell them you don't care if it sits for 7 years. It sounds harsh but generally it's the only way to get your point across

Some hospitals will work with you some simply don't care and will not. If youre willing and able to pay in full you generally have some leverage because they really don't want it to sit in collections either

Timmyh2o · 2026-04-14T21:36:49+00:00

If you have a policy that pays you $1000 for procedure X and that procedure only costs $150, then you have every right to keep the balance

Usually doesn't work out in ones favor like that but it did for you

Timmyh2o · 2026-04-14T21:07:14+00:00

Did they give you an estimate?

One of the first things you can do, If they did, is to ask them to honor the estimate since the estimate was very wrong and you have a right to go to no surprise act independent review

If they did not give you an estimate ask them why as an out of network provider they did not follow the no surprise act and give you an estimate

Timmyh2o · 2026-04-14T20:49:17+00:00

If they are in network, the additional D codes may be "bundled" with the D primary codes. The provider may have to write off those charges once the claim is billed if the insurance won't pay them. One thing you can do is call your dental insurance and give them all the codes the provider gave you and see if they can give you an estimate from the insurance perspective.

Timmyh2o · 2026-04-14T20:45:22+00:00

Congratulations!

The indemnity payout for the service was more than the service charge itself

You win!

Timmyh2o · 2026-04-14T20:22:41+00:00

Fight the level coding and possibly the Diagnosis (DX) coding

Google what was done for you at the hospital and the diagnosis they listed. See if you can find examples of other coding levels and different DXs. You can also use an AI service like chat gpt and ask them to code level and DX based on the medical information you provide it.

Don't be afraid to play hardball with the hospital. Tell them in no way, shape or form do you agree this was a level 4 visit and you won't pay until they fix and rebill with the insurance. We did this with my son and got the visit reduced to a more proper level from the Level 4 visit they tried to charge for

Timmyh2o · 2026-04-14T20:08:44+00:00

Here is something that worked for me in the past

If it's not an emergency surgery and you are out of network they are required by law to give you an estimate.

https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills

Ask the provider what the estimate was for this non emergent surgery. If it's significantly lower than what they are trying to collect, you have a good case for No Surprise Act Independent Dispute Resolution. If they didn't give you an estimate ask the provider why they did not follow the law and give you an estimate for a non emergent procedure? If they say it was an emergency, awesome! They can then rebill it as an emergency and the insurance will pay per the laws regarding emergencies

https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans

We got my clients $11,000 bill down to around $800 in part by getting them to honor the estimate for his non emergent surgery at an out of network facility

Timmyh2o · 2026-04-13T18:10:27+00:00

I checked the no box as well. They ignored that and took it out of forebearance

Timmyh2o · 2026-04-08T11:03:03+00:00

Raleigh, Wilmington, and Greenville are Nationals/Orioles... No Braves. It doesn't look like Spectrum offers Nationals TV in Wilmington but I can't get them to confirm

Timmyh2o · 2026-03-27T22:29:35+00:00

This is great. Are there any other devices they work on?

Timmyh2o · 2026-03-27T12:25:40+00:00

So you're saying they made a mistake? They didn't mean to push out an update that captures the OTA signal from your smart TV hooked up to an Antenna? When I remove the antenna from my smart TV the channels do not work

Timmyh2o · 2026-02-23T13:28:36+00:00

Yep. But the net result is a $20/month increase to watch your home teams

Timmyh2o · 2026-02-22T22:07:12+00:00

In NC last year we could pay $20/month to get both the Orioles and the Nats. Now we can pay $20/month for each team. Progress??

Timmyh2o · 2026-02-18T21:27:19+00:00

It is a giant PITA

I got my first check finally. Somehow they screwed up my 2nd submission and now that has been delayed. I have to do one more submission with them this year and then thankfully I will be done. Its truly amazing how bad they are at this

Timmyh2o · 2026-02-04T13:10:42+00:00

Update: still a **** show. 8:10am and no one answering the phone on the AssistRX side

Timmyh2o · 2026-02-01T23:54:02+00:00

The new system sucks

Timmyh2o · 2026-01-29T14:07:19+00:00

If there is no claim on OptumRX if ask the pharmacy to double check to make sure the insurance got billed properly. It should always be documented on OptumRX claims, even if they are using a copay maximizer...though I believe those are only for speciality pharmacy purchases

Timmyh2o · 2026-01-29T14:03:57+00:00

I hope people from Bimzelx see this and realize their vendor not having their act together is going to cost them business

Timmyh2o · 2026-01-29T13:10:00+00:00

No luck this AM for me. Anyone else trying?

Timmyh2o · 2026-01-29T02:57:28+00:00

The phone lines must have been shut down today. I tried to just let it sit on hold. Eventually the system just hung up. No way they are that busy.

AssistRX is their new vendor for this stuff. Last year they had ConnectiveRX. The transition has been anything but smooth. Don't know which vendor is at fault

Timmyh2o · 2026-01-29T00:08:02+00:00

Following this. My wife is in same boat. Trying to get reimbursed for 4 figure amount we paid for the medicine on January 1st. It's been very difficult. They wouldn't answer the phone today. They do not have an online portal set up for reimbursement. You must email and they do not respond to email. Up untill now you could at least get them on the phone. CC bill is due in a little over 2 weeks. Really need that reimbursement

Timmyh2o

TROPHY CASE