Claimed denied because I used a PPO Provider?This doesn't make any sense to me, so hopefully someone can help me out. I just received a denial letter from my vision insurance provider, Spectera, for an eye exam and pair of glasses I got almost a month ago. I used their provider locater to pick the place, went there, paid my co-pays, and now they denied it in whole for this reason: "Benefits were used through a ppo provider."
What does that mean? Don't they want you to use one of their PPO or in network providers? That is what I did and now they denied it. That was pretty much the only explanation. I can't call their customer service until Tuesday, so I'm wondering if anyone has any advice on this before then. Thank you!
I'm not sure -- it doesn't say anywhere. They don't have ID cards, their website only shows my copay schedule, and the "benefit brochure" I have doesn't say if it's PPO or HMO. I assumed it was a PPO.
Thanks for the replies. Of course the website doesn't have ANY information about my benefits other than the copay list, so it didn't help. It just says to refer to my Covered Benefit or Exclusion section, but it doesn't have any relevant information.
I used one of their in network providers...
Posted by Banbalan B
Are you sure that you also have a PPO plan in the vision plan? I have a PPO in medical, but an HMO for dental.
Posted by CHUMPS
Very interesting. You want to contact (see link below) Soectera for an explanation. It may have accidently been coded incorrectly. This happens fairly often.
Q: How do I know what is covered under my plan?
A: Once enrolled in a Spectera vision care program, members can access information about their comprehensive vision benefits anytime, day or night, through our state-of-the-art Web site. For specific plan information, simply login and select the My Benefits section of this site. You may also contact your benefits manager for more information about your vision plan.
https://www.spectera.com/memberLogon.jsp
Posted by Lori S
Are you sure you are reading the EOB correctly? It doesn't sound like they denied it, but without seeing the EOB, I can't provide any better answer. If you used a PPO provider, there should be an allowed amount(this is the amount the insurance would consider for payment ), a provider responsibility (this is the amount the provider would write off as a contractual agreement with your insurance) and patient's responsibility (this is your co-pay and co-insurance if applicable.)
Posted by mbrcatz17
Well, the strong possibility exists that they denied this in error.
Sorry, you're going to have to wait until Tuesday. But if I were you, I'd go back to that provider locator, and print out the page that shows that they are, indeed, a provider.
Posted by Angee
well, to me, it sounds like it was denied in error. however, if it was denied correctly for some reason, it sounds to me like you did enough sufficient research and should file an appeal. i work in health insurance appeals and if i had your case, this is something i would probably approve. you did research but for some reason, something went awry.
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