Tracy called our office in a panic after being notified that her Medicare Advantage plan did not cover a lab she used. “My plan denied coverage of this $300 lab procedure because they said I didn’t get a referral!” She cried. “My Summary of Benefits book plainly states that I don’t need referrals,” she continued.

We reviewed her plan’s benefits book, and then we explained that her insurance carrier’s plan does not generally require a referral to see in-network doctors, but labs, x-rays, and diagnostics, do require a referral. And yes, unless there is a referral, your plan can deny paying the claim.

So we suggested Tracy pursue an appeal. Did one of her doctors request the test? If so, there would be a note in her file at the doctor’s office. We explained that she could appeal to the carrier to reconsider paying the bill. She would need to get a copy of the note from the doctor requesting the test and include it in her appeal. Most carriers have a 30–60-day appeal period if they initially deny a claim. So there is an element of time required in the appeal process.

Fortunately, our suggestion worked. Tracy was able to get the note from her doctor that said she needed the test, the appeal process with her insurance plan succeeded, and she got the claim paid! While this type of result doesn’t happen in every case, Tracy did the right thing by calling us when she encountered an issue so we could provide possible solutions!

Remember, we’re here to help.