Cpap Insurance Claims with online Out of Network Providers

If you file a claim with insurance for a cpap machine that was purchased at cpap.com, cpapsupplyusa.com or any other online and or course Out of Network supplier, does the insurance company verify that the machine was purchased with that company and will they reject the claim if they don't get a response from them. How do they normally contact them if they do contact them? Most of these online suppliers say then don't deal with insurance and to what extent is that true?

I have purchased three machines and lots of masks from online providers and just submitted the claims to my insurance company. I included, just to be sure, a copy of the prescription, the bill from the provider, and copies of the relevant sleep studies with the claim. For masks and supplies, the sleep study copies were not needed. My insurance just paid what they normally pay and didn't give me any hassle.

I suggest that you call your insurance company and see what they require in terms of documentation for online purchases. Do make sure that the online company provides in their bill all the information that your insurance requires, especially their [edit] Taxpayer ID number and codes for what you are buying. I believe that CPAP.com, Direct Home Medical, The CPAP People, etc. include this information as part of the invoice so if you buy from one of them, all will be good.

Best wishes.

JDS74 wrote:I suggest that you call your insurance company and see what they require in terms of documentation for online purchases. Do make sure that the online company provides in their bill all the information that your insurance requires, especially their license number and codes for what you are buying.

+1

it's entirely up to your insurance company, and they all seem to do things differently.

+! Check with your insurance company first.

A packing slip has always been sufficient for health savings accounts.
Insurance will be different; I have never had insurance that good.

Has anybody tried making a claim in the past year 2014-2015 with an insurance company in the USA (specifically anthem)? Since they got all this new insurance in place I think they have changed their internal company procedures/rules? Since the supplier doesn't deal with insurance then it would be an easy way to reject the claim. They send a letter to the online supplier and the supplier trashes the request for information. Then the insurance company says they are rejecting the claim because they didn't have any information from the supplier. The perfect way to cut payouts for online supplier purchases. I made purchases back in 2010 and had no problems with the claims for machines from online suppliers. I wonder is this is a tactic by anthem insurance to cut payouts and save money. Anybody work for anthem or know someone that does that is willing to talk about company tactics? Keep in mind the online purchase is a straight out purchase and they may not like doing this. They would rather it be a rental from a local DME where they can get out paying for it if the patient doesn't follow the rules for compliance. Anybody care to share their experience or what they know on new internal insurance company procedures?

Can only speak for CPAP.com...

They provide you with a standard 1500 form Called a:
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

It has all of the required information on it and is a proper form for all insurance companies.

As for Anthem, I dealt with them the beginning of the year to see about the purchase of my existing rental S9 VPAP Auto. They said they would accept the purchase from CPAP.com as an Out-Of-Network purchase. My Out-Of-Network deductible would be used until it was filled up before there were any benefits paid out. The amount deducted would be the standard 20% of allowable expense for the item. The Out-Of-Network deductable was $1500.

I chose not to do that as the deductible is quite high and the cost savings wasn't worth it. I ended up using the DME and having them submit it as a purchase instead which was In-Network and applied to that deductible ($850) which is now $0 for the rest of the year.

Note that if you are talking about a machine, you have to have a current RX for the insurance to pay anything for it. So if it is an older RX, you can buy it, but the Insurance company may not pay anything. I've never had issues with them paying for masks with an older RX.

BTW... I talked with Anthem several times over this and got a confirmation message in my mail about it. So if you have questions call them. Get who you talked to, date, time etc... I record all of my calls, but that is just me.

borgready wrote:If you file a claim with insurance for a cpap machine that was purchased at cpap.com, cpapsupplyusa.com or any other online and or course Out of Network supplier, does the insurance company verify that the machine was purchased with that company and will they reject the claim if they don't get a response from them. How do they normally contact them if they do contact them? Most of these online suppliers say then don't deal with insurance and to what extent is that true?

When I submitted my invoice to my insurance provider in 2005, I basically duplicated the invoice from CPAP.COM (because it had the billing codes on it) and also submitted a copy of the CPAP.COM invoice when I sent it in. That way, there was no doubt about the items I had purchased.


Den

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I'm checking into this right now (for supplies.) I have BCBS. The way it works (for my particular plan anyway) is that once deductible is met (in/out of network combined for me) they'll reimburse me at out-of-network rates, meaning 50%. Ironically it appears that my local DME (well, the insurance maximum allowable price) has the prices set so that it will be slightly less expensive for me to use them since insurance reimburses in-network at 70%. It looks like my best bet is to order from our hosts (or another online DME, but our hosts are very competitive on prices from what I've seen) until my deductible is met, then switch to ordering from my local DME until the deductibles reset at the beginning of the year.

What I haven't had answered yet is if I order the parts from Amazon or Flea-bay, can I get insurance to reimburse/apply to deductible? They are less expensive than our hosts (sometimes slightly, sometimes significantly) from what I've found, but if it doesn't count toward the deductibles it could wind up costing me a lot more in the long run.

BCBS had separate deductibles for in and out of network, which could not be combined.
WEASELS!

jjhall wrote:What I haven't had answered yet is if I order the parts from Amazon or Flea-bay, can I get insurance to reimburse/apply to deductible? They are less expensive than our hosts (sometimes slightly, sometimes significantly) from what I've found, but if it doesn't count toward the deductibles it could wind up costing me a lot more in the long run.

I could get my HSA to pay for the claim after providing them with the details for Amazon purchases that qualified, I've not tried ebay purchases. Insurance would not reimburse anything however for them.

Wulfman... wrote:When I submitted my invoice to my insurance provider in 2005

Lots of stuff has changed in 10 years.

chunkyfrog wrote:BCBS had separate deductibles for in and out of network, which could not be combined.
WEASELS!

I ran into that too. In-network is completely separate from Out-of-Network. different rates, different deductables. Although when talking to them on the phone, they seemed to get confused at times until I wanted them to validate it in writing.

jjhall wrote:I'm checking into this right now (for supplies.) I have BCBS. The way it works (for my particular plan anyway) is that once deductible is met (in/out of network combined for me) they'll reimburse me at out-of-network rates, meaning 50%. Ironically it appears that my local DME (well, the insurance maximum allowable price) has the prices set so that it will be slightly less expensive for me to use them since insurance reimburses in-network at 70%. It looks like my best bet is to order from our hosts (or another online DME, but our hosts are very competitive on prices from what I've seen) until my deductible is met, then switch to ordering from my local DME until the deductibles reset at the beginning of the year.

What I haven't had answered yet is if I order the parts from Amazon or Flea-bay, can I get insurance to reimburse/apply to deductible? They are less expensive than our hosts (sometimes slightly, sometimes significantly) from what I've found, but if it doesn't count toward the deductibles it could wind up costing me a lot more in the long run.

The important thing to find out is whether they consider you (the insured) to be in-network or out-of-network.
My insurance provider considered me to be in-network and reimbursed me at 80%.
I'd be curious to know why they would consider their own insured to be out-of-network. That doesn't make sense.
And, you can't just submit a copy of the invoice for the stuff you got somewhere else.......you need to create an invoice with you as the billing party and your insurance provider as the party being billed.


Den

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Krelvin wrote:

Wulfman... wrote:When I submitted my invoice to my insurance provider in 2005

Lots of stuff has changed in 10 years.

Maybe........maybe not. One thing that changed is that now I'm retired. But, other than that original purchase when I had met my deductible (only time), I never tried to ask them to help pay for any further stuff I purchased. I bought it all out-of-pocket. And, now that I'm on Medicare, I have no plans to try to get medicare to pay for any of this stuff either. Actually, I can't foresee that I would need anything else for the rest of my life.

But, I think that if I was still under my former employer's insurance plan and the conditions were the same, I could/would still do it the same way it did it 10 years ago.


Den

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Wulfman... wrote:I'd be curious to know why they would consider their own insured to be out-of-network. That doesn't make sense.

The in-network vs out-of-network is the vendor not the insured. they have special deals with in-network providers so they get a better deal and they want you to use them. Sometimes you don't want to use the "preferred vendors" which are in-network so you can use out-of-network vendors, and the different rates and deductibles apply.

Krelvin wrote:

Wulfman... wrote:I'd be curious to know why they would consider their own insured to be out-of-network. That doesn't make sense.

The in-network vs out-of-network is the vendor not the insured. they have special deals with in-network providers so they get a better deal and they want you to use them. Sometimes you don't want to use the "preferred vendors" which are in-network so you can use out-of-network vendors, and the different rates and deductibles apply.

If YOU submit an invoice to your insurance provider, then YOU are a "vendor". If you're also an insured member, then it should be logical that YOU are in-network as well.


Den

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