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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Claims Payment Seems Arbitrary

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Question: I had a chiro adjustment 4 times, and electric stimulus and my insurance paid. Then for the next three, exact services, they denied. Then 4 times after the denial they paid again for same service. I appealed but they denied. Why would they pay for a service, then not pay, then at later date pay again. I’m confused. If I bring this to their attention, can they go back and deny the previously paid claims?

Answer: The most frequent reason for claims payment variations is the service codes the provider enters when submitting the claim are incorrect. You can also have errors in the carrier’s claims department. That may account for the hit or miss nature of your chiropractor claims. First of all, you need to know your coverage. Call your member services hotline. The number is on your insurance card. Have them explain your chiropractic coverage so that you know it. If you have been paid for benefits you are not due, you will probably want to keep quiet. If they owe you, raise hell.

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