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» LymeNet Flash » Questions and Discussion » General Support » Horizon Blue Cross Blue Shield of NJ PPO High plan coverage at LLMD?

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Author Topic: Horizon Blue Cross Blue Shield of NJ PPO High plan coverage at LLMD?
Gerald
Junior Member
Member # 20898

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I have found two local lyme literate medical doctors near Bridgewater, NJ (central NJ) through this website. THANKS SO MUCH.


Can anyone explain how the insurance thing works? I've been told that most LLMD's do not accept health insurance.


I have the High PPO plan from Horizon Blue Cross Blue Shield of New Jersey. The plan allows for out of network coverage with a 30% coinsurance for me and they will pay 70%.


Does that mean that my insurance will pay 70% of the bill Dr. E charges me here in central NJ? So I will only have to pay $300 of the $1000 bill?


Will my insurance pay for the IgeneX test if Dr. E suggests that?


thanks, Gerry

[ 06-25-2009, 09:28 AM: Message edited by: Gerald ]

Posts: 5 | From Bridgewater, NJ | Registered: Jun 2009  |  IP: Logged | Report this post to a Moderator
bettyg
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hi gerry,

copy name of your health co. to subject line; you'll get more readers/replies then ok my new friend.

click on pencil to open up subject line... good luck [Smile]

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AliG
Frequent Contributor (1K+ posts)
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Dr. E - $1000 bill? I'm hoping that's just a random number for illustration of insurance %.

Usually they will pay their pecentage based on whatever they deem to be "usual & customary" for physicians of the same credentials.

I had BC/BS HMO so I can't really comment on what they will/will not cover for your labs.

IGenex was out of network for me. If it's the male Dr.E (there are two in NJ), he'll work with whatever testing your insurance will cover.

--------------------
Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner.

Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006  |  IP: Logged | Report this post to a Moderator
TF
Frequent Contributor (5K+ posts)
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Igenex does not take any insurance but Medicare.

So, you will be reimbursed for Igenex testing based on your out-of-network coverage.

If you read your brochure, it will tell you if they pay 70% of the bill or 70% of the usual and customary charges for these tests. I had BC/BS federal when I had Igenex tests done. They paid about a third of the cost of the tests.

[ 06-24-2009, 11:21 PM: Message edited by: TF ]

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maureen2174
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Dr. E doesn't charge $1,000, or even close to that. I have decided not to submit anything to insurance afterwards and just pay out of pocket. don't really want this lyme thing on record, if you know what i mean.....
Posts: 871 | From NJ | Registered: Mar 2007  |  IP: Logged | Report this post to a Moderator
bettyg
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gerald,

on whoever you are talking about, please send the below info to me by PM, PRIVATE MESSAGE; that's what we have used earlier talking to each other & llmd list i sent you ok.


I don't have the below info on the dr. you are discussing, please send it to me IF you have it or can get it after your appt. please to help others in future who need info. big thanks! [Smile]


cost per hour for 1st visit
and length of visit
cost for follow-ups
and length of visit

do they take insurance?
what kind?
treat by IV or ORAL?

thanks gerry for your help [Smile]

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Gerald
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Thanks so much for the info. Ali, the $1000 was a random number. I heard from someone else it is around $325 for the first visit and a little less for subsequent visits. Maureen, I know exactly what you mean about having it on your records. TF, my brochure only states that out of network they will pay a 70% coinsurance. Betty, I will help out how I can.

This group is awesome. I feel so much better just talking to you all. Thanks, a lot.

Posts: 5 | From Bridgewater, NJ | Registered: Jun 2009  |  IP: Logged | Report this post to a Moderator
bettyg
Unregistered


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gerry, we're here 23/7 ... normally 1 hr. when no one is here! so you can't get better hours than that, right? lol [Smile] xox
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lymephobic
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Gerald,

I have the same insurance as you... and yes they reimburse 70%.

I see a different Dr. than you and my LLMD uses certain language on the receipt to submit. PM if you are interested...don't know if I should post that here?

My testing was not done through IGENEX so I don't know about that. All my tests were through other labs and all covered.

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Gerald
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Thanks Lymephobic. I am interested in the info you speak about. I will PM you.
Posts: 5 | From Bridgewater, NJ | Registered: Jun 2009  |  IP: Logged | Report this post to a Moderator
randibear
Honored Contributor (10K+ posts)
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my bc/bs did not pay for igenex, out of network.

my llmd dropped all insurance. office visits are now around 200 i think....so i'm down to every three months instead of every month.

--------------------
do not look back when the only course is forward

Posts: 12262 | From texas | Registered: Mar 2007  |  IP: Logged | Report this post to a Moderator
liesandmorelies
LymeNet Contributor
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Randibear,

Your story is all too familiar.

I have BC/BS California and they argue with me over every little thing.

I personally think it is insane that many of us can't even use our insurance for Lyme(I don't blame the LLMD's), but can you imagine if your Rheumy for instance told you they could not take you insurance for lets say Fibro or CFS??????

--------------------
aka: Lyme Warrior

In order to do "real" science, you have to have a "real" conversation with nature.

Well Behaved Women Rarely Make History!

"Just Demand your Rights"

Posts: 869 | From nor - cal | Registered: Apr 2008  |  IP: Logged | Report this post to a Moderator
tominnj
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Unfortunatly I have BCBS HMO myself. They actually paid for all of my Igenx and Shiel Lab work. All you have to do is ask Dr E. to write you a letter of "Medical Necessity" So when the first denial comes back, appeal with document stating that the test was deemed medically necessiary for the well being of the patient and thus her responsibility as well as professional opinion.

I kind of like that gold paper in Willy Wonka's chocolate bar to send in with claims. now they don't deffinately have to accept is, but if they don't they are in two positions. 1 - they would be disregarding a patients well being by questioning professional statments. 2 - directly interfering a doctors required treatment.

One more thing i was on the horizonblue.com site
under "Downloadable Forms" and somewhere in the was the patients EOB for different insurance levels. HMO Access was the only one I could see
that had "100% fully covered" under blood/lab work where as the other plans said "100% covered from authorized labratory" Might be a type, dunno might not

Posts: 9 | From Sea Girt NJ | Registered: Dec 2008  |  IP: Logged | Report this post to a Moderator
DakotasMom01
LymeNet Contributor
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Gerald Said:"my brochure only states that out of network they will pay a 70% coinsurance." I have the ppo too, but they don't say 70% of thier customary fees!


The only lab, NJ blue cross will cover in full is Labcorp. I just went rounds with them over this a few weeks ago, for another issue.

Note:: There is a gap between the bill and what blue cross will use as "their customary payment."

Example; A test is $300.00. Blue cross normally only pays 100.00 for this special test, thats what they will pay and you are stuck paying for the rest. Plus you will have the deduct to pay on this.

So its 70 % of thier customary payment, NOT the actual bill figure.

You can always call the 800- # and talk to some one there and have them explain it...you don't have to tell them what test is. Just say your dr may want you to have a test in an out of network lab.

--------------------
Take Care,
DakotasMom01

Posts: 371 | From NJ | Registered: Dec 2007  |  IP: Logged | Report this post to a Moderator
   

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