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

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#1 of 37 Old 05-04-2010, 08:55 PM - Thread Starter
 
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I have UHC PPO, which I know is a pretty common plan. I tried to get a gap-exception last time around, which they completely and thoroughly botched, enough so that a competent employee that I spoke with after the fact (to find out if it had ever happened) was incensed, and was adamant that I file an appeal.

The time before that, I hadn't heard of it, but they didn't pay much, which is why I wanted the exception.

This time, I'm hearing it might be better NOT to have an exception - it might be best to leave well enough alone and not contact them unless absolutely necessary.

So, I'm curious... Has anyone done both and noticed a difference in payout? My main goal here is to get them to pay my MW what she's due. I don't really care how that's accomplished, as long as she gets paid!

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#2 of 37 Old 05-20-2010, 10:31 PM
 
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We're switching to UHC in July, and I already have dh's HR folks lined up to deal with them for me

What they've explained is that if we pick HMO the gap coverage will cover at in-network rates (reasonable and customary?) for the midwife. Then she can balance bill the difference to us.

IF we pick PPO then she will be covered at their out-of-network rates, and can still balance bill us the difference.

Either way we can also dump $ into our HSA/MSA (forget which) to cover the difference.

What it really comes down to for me, is what will our OOP cost be for the insurance (HMO vs PPO) because either way my chiro is also not covered, so it might be worth it to go HMO for the cash in our pocket each check.

Her cash rate is $4k, and global billing is $4600. Reimbursement from UHC can be as low as $2200 (I'm going to get the ICD9 codes and call them for specifics once I have the plan details).

So max, with the HMO plus some supplies, I see our max OOP at $2500. With the PPO it could be higher, since out of network will reimburse at somewhere between 60-80% (still don't know the details of the plan).

If we went cash, we'd obviously pay the full $4k. I'm so sad, we're currently on BCBS PPO which covered my son's hb at 100%, we just rented a tub and got some basic supplies.

I'm hoping the PPO vs HMO difference is as large as it was with BCBS (it was over $100/mo) and that will really help to offset the OOP cost for the birth if we get the HMO. Either way, I'm sticking with the midwife we have and I'll really give HR a hard time if UHC screws it all up.

Lisa, mama to Lauren, Elliot, angel Marion, and baby due in the fall.
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#3 of 37 Old 05-20-2010, 11:27 PM - Thread Starter
 
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It's all so complicated, isn't it? We haven't switched insurance in many years now (not companies, anyway, though the policies have changed constantly), so we haven't had to do quite that amount of juggling.

Your reimbursement amount sounds alot like what we've gotten. We actually, though, just got notice of a class-action suit against UHC about out-of-network claims not being reimbursed properly. I'm hoping that our homebirths will be part of the settlement, as we got so very little out of UHC for them. They're also supposed to be changing how they evaluate the claims, so, again, I'm hoping it's in our favor!

As for gap versus simply global billing, I'm going with just global billing and not messing with anything more than necessary. I have a local friend using the same MW who has the gap exception (and due within 10 days of me), and we will be able to compare payments. They should be identical, but if they're not, we can appeal based on the other payment for whomever got short-changed. That seems like a good plan to me, anyway!

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#4 of 37 Old 05-21-2010, 09:48 PM
 
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I'm clueless as to what gap extention and global billing mean but we had UHC PPO when we gave birth. They said upfront that they'd pay our midwives 60% of their fee. Our midwives did some creative biliing and billed for some prenatal care, home visits, and newborn exams and the amount that UHC paid them was closer to 92% of their fee.

Heather Mike Married 8/1/99 Mom to Charlotte Aug 04, Nov 06, and Katherine Oct 07
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#5 of 37 Old 05-22-2010, 02:14 AM - Thread Starter
 
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That's fantastic, Belle! Do you happen to know what codes they used, or specifically what they billed for? I hear most people get better payments billing globally (same code an OB does), but perhaps separating some of the care can work out in one's favor.

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#6 of 37 Old 05-22-2010, 08:01 AM
 
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i too have uhc ppo and we are working on getting hb covered. i think we are using the whole gap scenario.....nothing in writing yet from uhc, but when i have it i will let you all know how it turns out.

i *think* what will happen is that we are responsible for our in-network deductible and uhc will cover 65% (the out of network percentage) of our midwife's bill.

married to DH for 5 yrs, ds born at home 6/26/10
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#7 of 37 Old 05-22-2010, 11:00 AM
 
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Quote:
Originally Posted by HeatherB View Post
That's fantastic, Belle! Do you happen to know what codes they used, or specifically what they billed for? I hear most people get better payments billing globally (same code an OB does), but perhaps separating some of the care can work out in one's favor.
I don't know the specific codes. I just got a statement from the insurance company that prenatal care had been applied to our deductible before we met it. After the birth I got the statements that they paid 60% of the birth fee. Then later that they paid home visits and newborn exams. We had already paid the midwives' fee which included everything so we got reimbursement checks from our midwives for months after the birth. It was great.

Heather Mike Married 8/1/99 Mom to Charlotte Aug 04, Nov 06, and Katherine Oct 07
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#8 of 37 Old 05-22-2010, 05:49 PM - Thread Starter
 
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My understanding is they should pay it ALL based on in-network rates. I hope it works out for you! They made it virtually impossible for me last time, and I hear that's not uncommon.

Belle, that is awesome!

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#9 of 37 Old 05-22-2010, 11:24 PM
 
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My midwife said that the problem isn't so much that they will pay at their in-network rate, but that their in-network rate sucks compared to other companies. She said that last she checked, their "usual and customary" for a vaginal birth (regardless of location, hospital or home) was reimbursed at $2200. That doesn't cover her costs, so she'd lose money on a birth.

So we're going to hope they pay their max, and that it's higher than $2200, and we'll pay the difference OOP.

Lisa, mama to Lauren, Elliot, angel Marion, and baby due in the fall.
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#10 of 37 Old 06-04-2010, 01:48 PM
 
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whew!! sorry it has taken so long to get you guys actual concrete information about what my particular case is, but here goes:

my mw's billing person applied for a gap exception. this process was started on her end on 5/13, for some reason UHC doesn't have entered until 6/1.

so I have called several times per day to check on the status. make sure you get a reference number. there are 2 800 numbers you can call: 800-638-3323 or 800-638-7204 (option 2, then option 1)

long story short, they approved our homebirth to be covered in network!!!!!

and for those who want the codes, apparently 59400 is the delivery code.

good luck....it's been a long frustrating wait for us but we are obviously thrilled with the results!

married to DH for 5 yrs, ds born at home 6/26/10
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#11 of 37 Old 06-04-2010, 02:39 PM
 
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I found out yesterday that if you are w/in 3 months of your EDD you can apply for a transfer/continuance of care (it might be law?) within 30 days of UHC becoming your insurance, and they will pay your care provider at in-network rates even if they aren't.

We are doing this... we switch to UHC July 1, and my EDD is 9/28. Literally hours from the 3 month period ending. I'm positive I'll go into October before baby is born, but the coverage is based on your EDD via LMP, so I qualify.

Yay!

Lisa, mama to Lauren, Elliot, angel Marion, and baby due in the fall.
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#12 of 37 Old 06-22-2010, 04:44 PM
 
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This thread is kinda old but my billing issues were just finalized, so I came here to share what worked for me.

I believe it is best to get the exception. The insurance company might have the right to deny out of network claims or reimburse at lower rates if you do not obtain prior approval. Plus, it is just fun to think that someone from your insurance company is calling every single OB and midwife in their network within whatever radius to verify that they don't attend homebirths.

I have a BCBS of Illinois PPO plan. My individual deductible is $1k in-network and after that they pay 80%. For out of network providers the deductible is also $1k but thereafter bcbs will only reimburse 50%. Naturally my CNM, who runs her own business specializing in homebirths, is out-of-network for all insurances. But since bcbs does not have any in-network providers who will attend a homebirth, I applied for and was granted a PPO Waiver. They sent me a letter stating that they would reimburse the homebirth charges at in-network rates and my in-network deductible would apply. The waiver was good for 60 or 90 days after I applied, and could be extended if I needed it to be. I applied for the waiver in mid-February and was due early-April so the original waiver worked out fine.

Prior to 36 weeks I was too pay my midwife $1500 of her total $4200 fee regardless of the way insurance turned out. After my homebirth, my midwife billed BCBS her global fee. BCBS initially "overlooked" my waiver and tried to apply my out-of-network deductible and paid only 50% of what was left, approving $3700 as "reasonable and customary". As soon as I received my explanation of benefits, I called them and reminded them of my waiver. They sent the rest of the appropriate payment the next day. I was planning on paying the remaining few hundred dollars that BCBS considered unreasonable (whatever!) but my midwife's assistant had already billed separately for my Rhogam shot (the EOB read "injections") and some newborn procedures (EOB read "Physical exam), and possibly also my pap at the 6 week postpartum appointment? BCBS ended up paying small portions of those, which made up the difference.
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#13 of 37 Old 06-22-2010, 05:32 PM - Thread Starter
 
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Glad you had such a good experience, frenchkissed! I wonder if the differences I'm hearing are due to UHC's policies. I am very curious what will happen between my friend and I when we have our births billed - one with the gap exception and one without. I'm very grateful that we can appeal to have the lower coverage adjusted to the higher level for whomever that ends up being, as I hate to lose anything or have my MW lose out!

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#14 of 37 Old 08-19-2010, 09:24 PM
 
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Any updates Heather (or anyone else) on the best way to deal with UHC?
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#15 of 37 Old 08-19-2010, 10:43 PM
 
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It's so funny that this thread got bumped up! I'm with UHC under a PPO plan. I got a gap exception approved for my midwife: my out of network deductible is $2,000 whereas my in network deductible is $1,000 so I figure the difference was worth it. Since the major of my prenatal care will be in this year but the delivery in next year, it's very likely they'll want me to cover the deductible for both years. UHC wasn't too bad about the gap exception but getting my primary care physician's office to call it in was like pulling teeth.

Now I'm running into a speed bump where I assumed that a home visit would be covered the same as an office visit. Instead of a copay, it is subject to coinsurance (so I need to fulfill the deductible and then they will cover 80%). My midwife doesn't plan to bill them again until the baby's birth. So I'm trying to figure out how to procede. My midwife has the option of office visits but it's a good distance to her office. She works with a biller but she hasn't been helpful and told me to call UHC to ask about coverage. Of course I worry I'm not asking the correct questions.

That was probably longer than it needed to be but when I talk to my hubby his eyes just glaze over.

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#16 of 37 Old 08-20-2010, 01:12 PM
 
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Does anyone else's midwife use a biller who doesn't seem to know what's going on? I emailed the biller and she claims she billed the insurance for an office visit while the explanation of benefits very clearly states "home visit".

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#17 of 37 Old 08-21-2010, 01:16 PM
 
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Allison, tell her the icd9 code is wrong, and that it's showing as a home visit, and you need her to resubmit. Though every time I call UHC they tell me that "location doesn't matter" and provider does.

And talk to your midwife, she might be able to come up with some other things to add on the bill, hydrotherapy for pain relief, or something else, that will give you "more" to bill so she gets reimbursed a little more.

My opinion at this point is that UHC sucks.

I switched to the UHC HMO July 1, and did a ton of paperwork to get them to do a "continuance of care" form (they told me to do it) and then rejected it because continuance of care isn't covered by the HMO, only by the PPO. I can't get a gap coverage because there is ONE hospital midwife (1.5 hrs away) who is within the 30 miles of coverage. So I'm now appealing the continuance of care. I should qualify for that because my edd is 3 days before the 3 month window the continuance covers.

My midwife won't even ask her biller to bill UHC, I'm going to have to submit it myself, because it's a pita for them to do. They only bill BCBS PPO.


BUT more importantly, I've talked to several women who have gone into a homebirth KNOWING that UHC wouldn't cover their provider/homebirth. They've paid their midwives up front, and then sent a really nice letter to UHC explaining that their homebirth (at 4k or so) actually saved the insurance company a ton of money (vs the cost of a hospital vaginal birth, vbac, or c/s) given the actual cost plus 2-5 days stay at the hospital, etc. etc. and UHC has quietly issued them a check for a big chunk if not all of their homebirth costs.

SO... once this is all said and done, and we have a balance to pay the midwife (we will, because I already know UHC reimbursement rate is lower than what my midwife will accept, so I will pay her out of pocket for the difference), I plan on sending a letter to UHC to ask them to reimburse me the difference that I pay OOP because the $1000 I pay OOP will obviously still be far less than what they paid her vs. the cost of a hospital birth.

I figure the worst thing is they say no.

Lisa, mama to Lauren, Elliot, angel Marion, and baby due in the fall.
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#18 of 37 Old 08-21-2010, 01:29 PM
 
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Lisa - When I talked to UHC, they did seem to see the difference between home and office visits. I'm not sure what you mean by code. Is icd9 the code she should use or the code she should not use?
But when I emailed her back about the claim and said it was definitely showing as a home visit as she could see on the EOB I sent to her and she replied with something along the lines of "oh yeah first visits are often office visits but yours wasn't".

I did send an email to my midwife (since the biller isn't being particularly helpful) and asked if it would be possible for visits to be billed as office visits to get the maximum reimbursed amount. I'm hoping she will be just fine with that ethically.

It sucks that insurance make such an issue over covering homebirths when the cost is way less than a hospital birth.

Mama to Blake, 5, and Grant, 3
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#19 of 37 Old 08-21-2010, 02:01 PM
 
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icd9 is just the name of medical billing codes. So she needs to find the right icd9 code to use.

Like the ones I know off the top of my head are:

vag birth 59400
nst 59025
nb exam 99461
postpartum visit mom 99350
hydrotherapy for pain mgt 97036

And those get sent in with a dollar value attached, and reimbursed. They also need a diagnosis code with them (pregnancy, vaginal birth, labor services, etc.) or the insurance company won't pay for a service is there was no diagnosis to warrant the service.

Lisa, mama to Lauren, Elliot, angel Marion, and baby due in the fall.
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#20 of 37 Old 08-22-2010, 12:41 AM
 
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Lisa - UHC is willing to cover the claim once I reach my deductible. It's not that she's billing it incorrectly; it's that UHC is treating home visits different from office visits.

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#21 of 37 Old 08-22-2010, 04:50 PM
 
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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.

Aimee wife to Matt Mama to Asher (4) and Ari (Due 11/6/10)
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#22 of 37 Old 08-24-2010, 03:52 AM - Thread Starter
 
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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!

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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#23 of 37 Old 08-24-2010, 04:12 AM
 
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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.

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#24 of 37 Old 08-24-2010, 02:48 PM
 
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Originally Posted by SumnerRain View Post
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.

Aimee wife to Matt Mama to Asher (4) and Ari (Due 11/6/10)
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#25 of 37 Old 08-24-2010, 05:14 PM
 
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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.

Heather: Mama to my amazing boys A-14.5, C-13, & M-5.5, and my sweet girl S-2.5 and introducing our little surprise Liam Michael, born 12/28!
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#26 of 37 Old 08-25-2010, 05:35 PM
 
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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.
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#27 of 37 Old 12-06-2010, 08:59 AM
 
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Bumping to see if HeatherB has an update on coverage orngbiggrin.gif


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#28 of 37 Old 12-07-2010, 11:41 PM - Thread Starter
 
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Baby is here joy.gif 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.


HeatherB ~ mama to 3 wonderful boys:  reading.gif 03/02; modifiedartist.gif09/04; sleepytime.gif 09/07 - and Eliana, babygirl.gif 11/13/10!  
Founder of Houston Birth Alternatives: Be Informed, Encouraged, Supported birth support group and aspiring midwife.

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#29 of 37 Old 12-08-2010, 06:17 PM
 
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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!


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#30 of 37 Old 01-05-2011, 09:08 AM
 
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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.  

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