Denied Insurance Claim

I received an EOB (explanation-of-benefits) in the mail today for my husband.  We had just changed our insurance on the first of the year from a HMO to a PPO.  We decided we needed a little more flexibility with our choices.  The HMO would have been less money out-of-pocket for us, but the monthly premiums were higher.  We hoped that we wouldn't have any "major" issues that we would have to pay out towards our deductibles and co-pays this year.  WRONG ANSWER (that’s a whole other blog).   I’m looking over the EOB (see attached) and it states:  Total Charges: $160.00 (for an office visit only).  Amount Not Allowed:  $81.51; Deductible Amount:  $78.49; Amount Paid: $00.00 BUT THE BIG CLINCHER was on the messages:  *** It is your responsibility to pay:  $160.00*** There is a section on the EOB that says Physician Member:  NO.  Hmmm, before my husband chose his physician, he did his homework.  He went to the insurance website and made sure that he was a participating provider; which he was.  He presented his insurance card at his office visit to the receptionist.  There was nothing said to him that the doctor was NOT a participating provider.  So far, everything that he did was correct.  Now some people would just go, “oh well, I messed up, I need to pay the $160.00”.  Not me.  I could have called the doctor’s billing office, but I decided to get to the heart of the matter.  I went directly to our insurance company.  There’s a phone number at the bottom of the claim for customer service.  I had all my ammo ready.  I had the insurance card available, and had the insurance website up showing where the doctor was a participating provider.  After waiting on the line for about 30 minutes, I was able to speak with Tina.  She could not figure out why the claim wasn’t paid either.  She checked her information and saw that the physician was a participating provider.  She said she would send the claim back through for an adjustment (a fancy term indicating they would reprocess it) and it would take 2-3 weeks.  I documented the date and time I called, who I spoke with (Tina), the outcome (sent back for an adjustment) and asked for a “tracking number” for this call.  What went from possibly owing $160.00 went down to a $20.00 co-pay.  There could have been one other possible explanation for the insurance error.  Some physicians have two entities; i.e. John Johnson, MD and a group name, i.e. Johnson Family Medical Group.  Sometimes, not both are associated with the contracted insurance companies.  John Johnson MD may have a contract, but if the claim was billed under Johnson Family Medical Group, (who isn’t contracted) the claim would be denied.  If this ever happens to you, ask the insurance to reprocess it correctly.  If they won’t do this per your request, call the doctor’s billing company and ask them to resubmit a “corrected claim”.  I know I could use and extra $140.00, couldn’t you?