need advice on how to navigate this
I recently had an emergency medical situation for my daughter that required me to call 911 and be transported to the hospital by an ambulance (around 2-4 miles, no Iv/cpr/oxygen only pulse monitor). I am insured under a plan with meritain health a Aetna company.
ambulance service provider(ARMSTRONG ambulance) gave a bill of $4200 to insurance. Insurance applied a discount of $3300 and applied co payment of $900 to my deductible(my deductible for a individual is 3000K) and paid no money to the ambulance provider.
Ambulance company said that they have no Contract nor accept any reduction/discount on their Emergency Services and they are billing me for the full amount $900(my responsibility) + $3300(the discount applied by the insurance company).
I filed a appeal with my insurance to process the claim for the full amount, they denied the appeal with below response:
We received your appeal regarding the ambulance claim on 1/18/23 from Armstrong Ambulance Service. We upheld the original decision. Armstrong Ambulance Service is a non-participating provider with your health plan. The claim processed toward the participating benefit level of 100% after deductible up to the usual and customary charges. Charges in excess of the usual and customary are not covered. The athenahealth Inc health benefit plan states the following:
“Usual and Customary Charge: Expenses in excess of the Usual and Customary Charge will not be considered eligible.”
Therefore, we are unable, according to the summary plan description language, to reprocess the ambulance claim as a covered benefit under the plan.
Meaning this was processed as in network; as the plan document allows) However Ambulance company charges are unreasonable.
I tried calling Ambulance company to negotiate the total cost to around 2k and pay it off but those guy are not giving any discount and asking me file a appeal again with insurance.
What do you guys suggest i should do? should i pay the full amount? This price seems un reasonable to me as well.
Note: I recently shifted to USA, I live in Massachusetts .
Billing code amount
A0427 $3300
A0425 $350
9300 $600
submitted by /u/Low-Ad6561
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