Here’s the situation: My daughter’s ABA claims got rejected by Allegiance, and they say it’s for timely filing. But the provider’s OfficeAlly shows these claims were submitted multiple times to Cigna within the timeframe. Allegiance claims they never got the claims, so they’re rejecting them. I’ve appealed this with no success and Allegiance blames the provider. I contact Cigna, and they tell me to call Allegiance. Now I’m stuck with the provider saying I’m responsible for all the rejected claims. The providers are all in-network. Is it possible for the claims to have been lost before being processed? I’ve heard stories about Cigna using algorithms to deny claims.
The provider and the insurance company need to handle this. Since they are in-network, you shouldn’t have to pay if the claim was denied for timely filing.
The provider insists they submitted the claims and even has forms showing this. But Allegiance claims they didn’t receive anything. How can things get so mixed up?
Dane said:
The provider insists they submitted the claims and even has forms showing this. But Allegiance claims they didn’t receive anything. How can things get so mixed up?
It’s possible the provider sent the claims to the wrong place, which might be why Allegiance didn’t see them. It could also be an error by Allegiance. Check your health insurance policy from your employer or insurance company for details on how to file grievances or appeals. Follow the grievance process to get clarity.
Dane said:
The provider insists they submitted the claims and even has forms showing this. But Allegiance claims they didn’t receive anything. How can things get so mixed up?
You mentioned submitting to Cigna for pricing. But that sounds more like checking costs rather than filing claims. Did you actually file them?
@Kiran
Actually, Cigna prices the claims first for Allegiance. The claim goes to Cigna for pricing and then is forwarded to Allegiance for payment. I just dealt with Allegiance claims recently, so I get your concern.
I think you shouldn’t be responsible for in-network claims that weren’t filed on time, but I hope others share their thoughts. You might want to file a complaint with your state’s Department of Insurance.
@Soren
I thought the same, but since it’s a self-funded plan, it doesn’t fall under the Department of Insurance. I’ve tried contacting the Department of Labor, but I haven’t gotten any answers.
Dane said:
@Soren
I thought the same, but since it’s a self-funded plan, it doesn’t fall under the Department of Insurance. I’ve tried contacting the Department of Labor, but I haven’t gotten any answers.
Could you contact your employer since it’s a self-funded plan? I had to appeal to HR before for my self-funded plans through the government.
@Jaden
I’ve tried. I keep getting pointed back to Allegiance, and they’re no help. It feels like I’m shouting for help in an empty field.
Dane said:
@Jaden
I’ve tried. I keep getting pointed back to Allegiance, and they’re no help. It feels like I’m shouting for help in an empty field.
Is there any union at your workplace? That might help your cause. Can you verify that the claims went to the right address or fax number? The right details should be on your insurance card. If they did, and the insurer keeps ignoring them, maybe consider media attention or speaking to a lawyer.
Dane said:
@Jaden
I’ve tried. I keep getting pointed back to Allegiance, and they’re no help. It feels like I’m shouting for help in an empty field.
If the provider is under contract, they can’t bill you. You’re not liable for their billing mistakes unless you didn’t give them your insurance info. If they keep pressuring you, just tell them to deal with the insurance side. Checking prices isn’t the same as making a timely claim.
If they’re part of your plan, they can’t make you pay. Call Cigna or Allegiance, ask to speak with a claims representative, and have them involve the doctor’s office. You’re not liable for denied claims for in-network providers.
Did the provider dispute this and provide any proof of timely filing to the insurance company?
I wish we had a union. Sadly, we don’t. The provider has records and proofs of their submissions, but proving Cigna isn’t doing things right feels impossible!