I’m irritated. More than even my usual self. I have always gone to my local outpatient immediate care center for flu shots and my insurance has always covered them. Every year. This year my insurance carrier decided to deny the claim, saying that preventative services provided at an urgent care location are not covered. They said to review my benefits book for details.
I look through my benefits book and it clearly says in multiple locations that preventative services provided at an in-network provider will be covered at 100%.
Routine preventive care services which do NOT require a
diagnosis or treatment are covered at 100 percent when
utilizing a network provider. Out-of-network preventive care is
covered at the out-of-network benefit level. Your doctor will
determine the tests and frequency that are right for you based
on your age, gender and family history. In-network preventive
services are not subject to the plan year deductible.
NOTE: Claims which indicate a diagnosis are not
considered preventive and are subject to the plan year
deductible and coinsurance.
The language about Urgent Care Services doesn’t seem to say anything about preventative care not being covered, it was more of a section on services that are covered:
Urgent Care Services
Urgent care is care for an unexpected illness or injury that
requires prompt attention, but is less serious than emergency
care. Treatment may be rendered in facilities such as a
physician’s office, urgent care facility or prompt care facility. This benefit applies to professional fees only. If a facility fee is billed, the emergency room deductible applies.
I went ahead and filled out the appeal information on the website, so I guess it is now a wait and see situation. I may call the “Plan Administrator” and see what they have to say. Either way, this sort of stuff is a waste of time and energy. For something that is a preventative health care issue no less.
Update 10/26/17: I have not heard back yet on my appeals, but I did get a call back from our insurance plan manager. They said they are still working on the issue but they suggested I contact the immediate care center and see if they can resubmit the claim as an office visit instead of as an immediate care procedure. They said if the immediate care center can not do that to contact them back and they would try to work my insurance carrier. The immediate care center said they will try to resubmit the claim as an office visit. I’m now waiting to see the outcome.