HELP help
My provider has a client who has a patient with Aetna and BCBs. Provider bills 155.00 for a session
Aetna pays 45.00, Client has a 20.00 copay. How much does BCBS pay. Is BCBS responsible for the 90.00.
I need an answer I can give the Provider and the Client.
Thank You
Wendy Stewart
775-240-0806
wastewart96@gmail.com
There's not enough information here to determine what BCBS will pay.
One key question is whether the provider is in-network with Aetna.
If the provider is in-network with the primary plan (Aetna), the difference between the billed charge ($155) and Aetna's allowed amount would generally be a contractual adjustment. (BCBS isn't going to be responsible for an in network contractual adjustment from the primary plan.)
If the provider is out-of-network with Aetna, there may be a balance bill amount remaining, depending on the provider's contract status and applicable state and plan rules.
The secondary BCBS plan is not automatically responsible for any remaining balance. Secondary payment would be determined by the plan's coordination of benefits provisions and will depend on factors such as:
• Whether the provider is in-network with BCBS
• BCBS's allowed amount for the service
• The patient's BCBS benefits, deductible, coinsurance, and copay requirements
• What Aetna already paid and/or applied to patient responsibility
Without knowing the provider's network status and the specific benefit details for both plans, it's difficult to say what the BCBS plan would cover after the primary Aetna plan.