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Inpatient stay is for 2 med surg days and 1 icu day. Drg is 288. Total charges are 30000. Patient benefits is 500 deductable with none met. What is the allowable rate How much will insurance pay?
Wiki User
∙ 7y ago
That depends on the conditions of YOUR insurance company ! WE are not privileged to the conditions of your contract with your medical insurance !
Wiki User
∙ 7y ago
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My husband's insurance covers his daughter as the primary but her mom carries dental for her now her insurance is refusing to cover her orthodontia due to the fact they are secondary- is this legal?
You do not say what state you are in and the exact answer could be a function of the insurance law for coordination of benefits in your state. However there also could be a specific provision in the Mom's policy--usually titled non-duplication of benefits--that says it does not pay if other insurance exists.Without a non-duplication provision, in general if the primary insurance company covers orthodontia, it will pay first and then the secondary insurance will pay some additional portion. There can be differences state to state but in general it works this way:The primary carrier pays the claims as if there is no other insurance involved. The COB law requires the secondary carrier to calculate what the benefit would have been for the claim if there were no other carrier involved, but allows the secondary carrier to deduct the amount paid on the claim by the primary carrier from its payment. The secondary carrier then pays the claim up to 100% of the allowable expense if the benefit contained in the policy is great enough. So, if the dentist's charge for ortho is $1000, but the allowable expense is $800; the claim will be paid based on $800 being the maximum that can be paid.There are two exceptions to this general rule. First if the primary carrier is a DHMO and the patient does not use a DHMO provider, the secondary carrier must pay the claim as if it were a primary carrier. As well, self-funded and collectively bargained employer groups operate under federal law and do not have to follow state COB laws. These groups often utilize "non-duplication" provisions to lower premiums. These provisions provide that that the insurer will not pay for benefits that are reimbursed by other insurance. Where these provisions are present in the patient's policy, there may not be any payment from the secondary carrier.An allowable expense is the usual and customary or maximum allowable expense for the dental service when the item is covered at least in part under any of the plans involved. When a covered person is covered by two or more carriers which determine benefits on the basis of usual and customary fees or maximum allowable expense, any amount in excess of the highest usual and customary or maximum allowable is not an allowable expense. When a covered person is covered by two or more carriers, which determine benefits on the basis of contracted fees, any fee in excess of the highest contracted fee is not an allowable expense.You might want to contact the consumer representative in your state Department of Insurance to help sort out your policy provisions.
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