The OOP is going to be filled in the order the claims are processed. AFAIK there is no “negotiation / pending status. Either the bills gets processed or it doesn’t. If part of it gets processed and paid, and part of it doesn’t then the additional amounts will be resubmitted and if approved upon review then they’d get paid by the insurance company to the provider.Suppose one has a HDHP.
The insurer pays nothing until deductible is reached.
The insurer also provides a max out of pocket.
An insured has a heart attack and goes to the ER.
The hospital submits their bill in a timely manner.
This event would easily max out the out of pocket maximum for the insured.
However, the insurer needs to "process the bill" and "negotiate with" the hospital.
In the meantime, other bills are incurred by the insured.
As the hospital bill has not been processed, the out of pocket maximum has not been reached and the deductible has not been met.
If the bill is 20k, and the out of pocket max is 18k, what happens with all the charges from other medical professionals, as the EOB show that no deductible is met , therefore, the insured must pay all of the negotiated rate, even though the out of pocket max was reached with the event.
What happens in such an event?
What are the time limits for the insurer?
Statistics: Posted by JBTX — Wed May 29, 2024 12:24 am — Replies 5 — Views 447
