How do these insurance co.s determine if they can cover your hospital bill?

I really need your help..Im trying to find information about insurance co.,like b.cross or b. shield.Has any one been coveredby them for an inpatient or short hospital stay?was it dr referred ?what was your experience?Or..does anyone work in an office that knows how insurance co.s determine if they can cover you?..What are some tips from people with similar experience..do you know what reasons they try to eliminate you or underwriters use to not cover you? It would be life saving ...please give as much detail if you know about the topic or have an exp youd like to share..thanks

I had to have an emergancy surgery, I had B/c B/s PPO. They covered the hospital but not the surgeon because he was out of network. (his office was next to the hospital which was in network) Had I had B/c B/s HMO I would have had to pay more because of the HMO limitations.

If you are having a procedure done, call B/c B/s and talk to a patient rep. Tell them what you are having do and ask if you need a referal. Get the name or employee number of the person, their extention or supervisors name and keep that with your records so you have something to referance if there is a dispute later on. Ask them to email you or fax you confirmation either way. Whether it is a yes or no.


To quickly explain how they (insurance companies) work.......

Insurance uses what is called an DRG Code (Diagnosis-related group) and an ICD-9 ( International classification of diseases- 9th edition) to determine your coverage.

Insurance companies have contracts with hospitals. They (ins.comp) agree to pay a specified amount for a particular procedure. The difference in what the Ins.co. pays and what every one else pays is called a discount and that is passed on tp you when you are billed. You get you EOB (explanation of benefits) amd it lists what the Insurance paid, what you paid and what the discount was.

By the way If you have a pre-existing condition the insurance company might deny you coverage on that condition for up to a couple years since last treatment,

You will get better answers using the correct category to ask. Although the sub-heading here is insurance and registration, the mail heading is cars and transportation, so you are asking health insurance questions in a car insurance place.