Wiki Insurance resp. for Newborn

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JosephGar

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Maybe you all can give me the right direction to go at this point. A child is bortn at the hospital. The mother is admitted under Aetna which does not need a authorization. The mother gives birth. I send the claim for the Pediatricain visit for the child and discharge date (99460 & 99238) to Aetna who tells me the child is not on the plan. As per Aetna they do not cover the child at all unless placed under their insurance. I find that the parents have placed the child from D.o.b. under Oxford instead. Oxford denies as no authorization was made. Both insurances are now denying payment.

Question: Who is responsible?

I would appreciate your advice.
 
If the mother had Aetna at the time of delivery then the child is covered for 30 days without having to be put on the policy. However, if the mother gave the wrong information to the hospital and she had Oxford on that date you may have a fight on your hands. Despite their commercials about how easy they are to work with, in my experience, they are one of the worst insurance companies to deal with as far as appeals and getting claims paid when patients give you the incorrect info.

Another possibility is the mother had Aetna and the father placed the child on his insurance, in this case Aetna is still responsible for 30 days after dob. I should qualify that this is state law in CT, other states may have different laws.
 
Thank you for responding, Ms.Clark. I spoke to the reps at Aetna and they tell me that they are not liable as the child was never placed under their insurance as per her policy. Perhaps it is different in NY or perhaps Aetna was "mistaken" but it is near impossible to keep up with all the different contracts out there. At least for me. I would hate placing this into the lap of the Parents but I see no other course if neither insurance carrier honors the
dates of service.
 
JosephGar said:
Maybe you all can give me the right direction to go at this point. A child is bortn at the hospital. The mother is admitted under Aetna which does not need a authorization. The mother gives birth. I send the claim for the Pediatricain visit for the child and discharge date (99460 & 99238) to Aetna who tells me the child is not on the plan. As per Aetna they do not cover the child at all unless placed under their insurance. I find that the parents have placed the child from D.o.b. under Oxford instead. Oxford denies as no authorization was made. Both insurances are now denying payment.

Question: Who is responsible?

I would appreciate your advice.
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Doreen's correct - they have 30 days under HIPAA to add the baby to the mother's plan. Usually (but not always), commercial payers provide coverage as a courtesy, for the 1st 30 days. It's important that the parents add the baby as soon as possible, because the special enrollment period is the only way that they'll be able to have coverage back-dated, to cover the birth.

I would also fight the no-authorization denial from Oxford. You can't feasibly get authorization for treatment on a patient who wasn't enrolled (or even born), prior to the DOS.

It's odd that the parents would opt to add the child to a different plan than the mother is on - it certainly complicates payment arrangements. The responsibility ultimately falls on them to ensure that they enroll the child in an appropriate plan. I would advise them to act quickly to correct this, since they'll be stuck with the bill, otherwise. Hope that helps! ;)
 
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