I am the law
Chicago,#2Consumer Comment
Thu, December 01, 2011
I obviously can't see your schedule of benefits, but here's what I think is going on.
The services listed on the claim probably aren't the issue. The problem is probably the diagnosis on the claim. It's most likely V70.3. This diagnosis, in the nutshell, means "services for administrative purposes"; which is to say it's for things like going to school, camp, travel, getting married, getting on a sports team, employment, etc. etc. Those reasons for care are rarely covered by insurance carriers. So, to say it another way, an annual child exam is covered, but a child exam expressly for the purpose of going to school isn't (despite the law saying the exam is required). Another example would be like immunizations being covered, but those same immunizations for going to Africa aren't covered. So, again, the diagnosis (or perceived reason for care) is causing the claim to deny. When health care providers put a V70.3 (or similar) diagnosis on a claim, it's literally the same as writing "NOT MEDICALLY NECESSARY" on it. Check your limitations and exclusions portion of your policy. I'm sure that it's covered there.
Hope this helps.