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

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#31 of 37 Old 01-06-2011, 07:49 PM
 
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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.   :)

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#32 of 37 Old 01-06-2011, 08:21 PM - Thread Starter
 
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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!

HeatherB ~ mama to 3 wonderful boys:  reading.gif 03/02; modifiedartist.gif09/04; sleepytime.gif 09/07 - and Eliana, babygirl.gif 11/13/10!  
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#33 of 37 Old 01-14-2011, 08:00 AM
 
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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!

 

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#34 of 37 Old 01-14-2011, 10:10 PM - Thread Starter
 
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That sounds very promising, MonkeysInk! thumb.gif

HeatherB ~ mama to 3 wonderful boys:  reading.gif 03/02; modifiedartist.gif09/04; sleepytime.gif 09/07 - and Eliana, babygirl.gif 11/13/10!  
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#35 of 37 Old 03-31-2011, 08:51 AM
 
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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.


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#36 of 37 Old 04-18-2011, 04:46 PM
 
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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. 

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#37 of 37 Old 06-28-2011, 07:57 PM
 
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Any updates?

Thanks so much for this info!

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