Experience with gap exception versus just global billing? - Page 2

[ARG2003]

I have UHC and was recently granted a Gap Exception. I was told that it would allow my MWs to be paid at in-network rate. My plan works like this:

1) I will have to pay my MWs there total $3,000 fee by 36 weeks.

2) My UHC plan for in-network is that that they pay 80% after my $500 deductible is met.

3) My MWs will submit the $3,000 as a global 59400 and the insurance will subtrct $500 for deductible and then pay out 80% of what is left, which is $2,000

4) My MWs will send me a check for whatever they get.

I am looking in to having them bill for NB exam, PP visit, hdrotherapy, etc to see if we can get more money back since they do that stuff anyway.

[HeatherB]

My baby isn't due until November, so I may not know for a while what happens. I am hoping they pay what's due to my MW, but also glad that my friend (with the same MW and due a week later) has the gap exception so I can appeal, if need be!

[SumnerRain]

I have UHC PPO and was approved for 3m of gap coverage, I have to reapply in a week for another 3m. I had to appeal because I was denied the first time, just appealed again because they changed my date and the 1st appointment was not in the covered time frame, waiting to hear back on that one since it may change my reapply date from Sept 7 to yesterday. UGH. I have an appointment with my MW in the morning and now I am stressing that I don't know if it will be covered without appealing AGAIN. I faxed the note 21 days ago, and got a letter in the mail stating they got my fax, but I still have no answer.

This is such a huge pain in the butt, but it takes their payout from 80% to 100%. I am not sure what their payout rates are, but I hope my midwife is compensated fairly. I guess I will know when she bills them after the birth. I guess I better get a copy of her codes tomorrow since it sounded like each time I reapply for gap insurance it is the exact same rigamorale as the first time with codes and begging my case and proving that the in-network people are not delivering, doing home birth, or accepting new clients, or are more than 40 miles away.

[ARG2003]

Originally Posted by SumnerRain

I have UHC PPO and was approved for 3m of gap coverage, I have to reapply in a week for another 3m. I had to appeal because I was denied the first time, just appealed again because they changed my date and the 1st appointment was not in the covered time frame, waiting to hear back on that one since it may change my reapply date from Sept 7 to yesterday. UGH. I have an appointment with my MW in the morning and now I am stressing that I don't know if it will be covered without appealing AGAIN. I faxed the note 21 days ago, and got a letter in the mail stating they got my fax, but I still have no answer.

This is such a huge pain in the butt, but it takes their payout from 80% to 100%. I am not sure what their payout rates are, but I hope my midwife is compensated fairly. I guess I will know when she bills them after the birth. I guess I better get a copy of her codes tomorrow since it sounded like each time I reapply for gap insurance it is the exact same rigamorale as the first time with codes and begging my case and proving that the in-network people are not delivering, doing home birth, or accepting new clients, or are more than 40 miles away.

Is your MW billing for individual visits or just a global (and maybe some other stuff afterwards)? I was told by UHC that even though they code it for items billed from the date the gap exception was requested through X date, if the midwife just billed for global, it doesn't matter when the FIRST visit was. Jsut the date the global was billed.

[SumnerRain]

Originally Posted by ARG2003

Is your MW billing for individual visits or just a global (and maybe some other stuff afterwards)? I was told by UHC that even though they code it for items billed from the date the gap exception was requested through X date, if the midwife just billed for global, it doesn't matter when the FIRST visit was. Jsut the date the global was billed.

Individual for the first appointment, which was just denied so she may have to stick with global. I will ask about that today when I call to find out if that is why visit #1 was denied and to extend my Gap coverage because they told me I had to renew it every 90 days. If that is the case though, that would help me stop stressing so much over all this.

ETA: Just talked to UHC and they said it *did* need to fall within the approved date, but appeal number 2 seemed to have done the trick and the start date is now back to May 25th.... and it looks like whoever got my letter went ahead and extended it until November 25th. I called today to start the process and she was confused saying it was good until Nov, and I asked her the start date since I still have not heard back from them and that is when she told me they moved it to when I originally requested it. YAY, looks like this time they READ my letter and didn't just send back a form letter saying "we have no claims for that date".

Oh, and the claim from the 25th was denied because it will coded global, but not billed global at the end of the pregnancy.

[MonkeysInk]

Every service has a procedure code and a location. On my insurance plan, for example: lab work, ultrasounds, x-rays are covered by our copay if they're done in the doc's office. The same things are deductible + coinsurance if they're done at an outside lab or the hospital. On the claims reports, each procedure comes across with a procedure code and a location code so that they can be paid correctly.

Our insurance specifically excludes homebirths, so I asked our MW about it. She said that since so many of the visits are done in her office, they can legally bill the global fee under the office code to get it paid by insurance.

[allisonrose]

Bumping to see if HeatherB has an update on coverage 

[HeatherB]

Baby is here  but I haven't filed my claim yet.  Actually planning to talk to my MW about it tomorrow!  My local friend with the same midwife had her baby about ten days ago, so I'm eager to see what happens with hers, too.

[allisonrose]

Awesome. Hope the insurance process goes smoothly for you and your friend.

I have to re-do my gap exception since they only let me do it through the end of the year the first time. Pain in the butt!

[MonkeysInk]

I just started working on a gap exception with UHC - thanks to everyone who's posted their information here, as it's been really helpful.

My plan specifically excludes homebirth, but the MW says they can bill it as in-office since I've had all of my visits at their office.

The person I spoke with yesterday at UHC was helpful, but since I didn't have all of the billing codes when I called, they couldn't open an exception claim for me.  Now I'm worried I'll call back and get someone totally useless.  

[Champ]

Gap exceptions are only for HMO plans.   PPO plans have INN & OON coverage.   Now, I'll have to research the midwife information and get back with you.   I can, however, tell you that for a gap exception for an HMO you have to have no access to an INN provider within 100 miles, I believe.   I am researching this because I am in this field and we had a few queries about a gap exception today and the system I use to access the information in black and white was not available.   However, the best way to get a gap exception is for your provider, example, your primary care physician call UHC on the provider line (which should be on the back of your card) and do this for you.  Good luck to you all and have a great evening.   :)

[HeatherB]

IME, with a PPO the gap exception is all about getting an OON provider covered as in-network. It's not that one wouldn't get *some* coverage, anyway, but that it (supposedly) would be better coverage and therefore advantageous. I have heard of concerns that raising too much attention (for anything, really) with an insurance company can mean they look more closely at claims and may end up paying *less* than they would've (and should've) originally. Still waiting to see how my (and my friend's) claims turn out to see if there's any difference, at least in this case!

[MonkeysInk]

So....I got two calls yesterday from UHC asking me to clarify some things, and a call this morning stating that they had approved for the global charge for my homebirth to be paid as in-network.  

I'm waiting to get the letter in a few days and will hold it tightly, but I was able to confirm what their reimbursement rate for in-network for the global charge is, and it's about $1200 higher than my midwife charges, which means that I'll get everything I paid her back.  Hooray!

[HeatherB]

That sounds very promising, MonkeysInk!

[allisonrose]

Coming back to share my experience to date. My son was born in January but due to a long, painful posterior-baby labor, we transferred so he was born in the hospital, not at home. I got a gap exception with my UHC PPO plan and boy am I glad I did! For 2010, I just had prenatal appointments. They handled those home visits differently than typical office visits so before the coinsurance kicked in, I had to met my deductible. If I hadn't gotten the gap exception, I would have gotten zero for the at home prenatal appointments in 2010. My reimbursement for the 2011 claims would have been significantly reduced without the gap exception as well. My midwife couldn't bill global due to the transfer.

My midwife had her biller bill for the time (about 36 hours) that she spent with us while I was in labor and that claim is still pending along with a claim for birth pool rental. There have been several claims denied because the codes weren't quite right and the biller is suppposed to rebill those. But they've processed my 2011 prenatal and postpartum appointments in network - well, I've had to call them a couple times because they processed it incorrectly the first time. According to my math, they are currently paying my midwife $1,800. Our balance with her is currently $2,400 (prepaid $2,000) so I hope they pay out at least $600 so we're all set with her. After all we have OB and hospital charges on top of the midwife fees. 

So my advice is to jump through the hoops and get a gap exception! I really hoped I wouldn't have to transfer but it happened.

Also I was told (indirectly) by someone who works for UHC that asking for a supervisor tends to get things done because the number of transfers to a supervisor goes onto the record of that employee and is considered indicative of their work performance.

[qadirqutiesmom]

Although this thread is old it seems like it may be really helpful for me. Anyone who can provide updates on their experiences with United since this please update or PM me. I'm currently 23 weeks and just wanting to make the switch to a CNM and will probably have to use an out of network CNM, because the only in network CNM in my area is full and can't accept me as a patient. 

[patricegonzales]

Any updates?

Thanks so much for this info!