I called my insurance company three different times to verify if my doctor is in-network, and I received conflicting answers. Two reps said yes, but one said no. My claim for the visit was denied as out-of-network, even though the insurance website lists the doctor as in-network, and the doctor’s office confirmed this as well.
Now the claim is under appeal, but it will take 30 to 40 days for a response. I have another appointment next week, and I’m worried this will happen again. How can we trust insurance reps when they give conflicting information? I feel stuck and frustrated trying to navigate this process.
If you’re going to the address listed in the insurance company’s directory, it should count as in-network. Take a screenshot of the directory entry showing the doctor’s name and address along with the current date to use in case you need to appeal.
Ask the doctor’s office for their NPI (National Provider Identifier) and use it to confirm network status with your insurance company. When you call member services, provide the NPI and ask for a call reference number to document the conversation. If your next claim is processed as out-of-network, you can use the reference number to request a correction. Sometimes billing errors happen because of how the system processes claims, so having this documentation can help.
Call your doctor’s office directly. They can often confirm whether they’re in-network when they verify your insurance. Be cautious, though—if this involves a hospital system, it’s possible for the hospital to be in-network while the provider isn’t, or vice versa. Sometimes it depends on who does the billing, such as the hospital versus an independent provider.
@Raj
This is probably what happened to me. My doctor and the address are in-network, but the billing came through under a different name, like ‘Medical Services LLC.’