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claim processing by insurance company
Dec 17, 2002

I was having my own medical insurance earlier.Then I switched to another company in August which provided me group insurance. In september I developed a small bleeding cyst on my back for which I took treatement. Earlier I received a letter from my new insurance company stating that they want a Hippa certificate to process this claim but now I have received a second letter from my insurance company saying that the Hippa certificate sent is not enough insurance coverage to avoid pre existing and they want the names, dates and diagnosis from earlier doctors visited. Can you tell me what it is all about?

Response from Ms. Franzoi

Under HIPAA, if a plan has a pre-existing condition clause (which it sounds like your new group plan does), the plan must recognize creditable coverage towards that pre-existing condition period. Creditibale coverage would include coverage under a prior plan provided you did not go more than 63 days without coverage. If you had coverage but went without coverage for a period of greater than 63 days, the pre-existing condition period would apply. If you did not go more than 63 days without coverage but were covered under the prior plan for a period of time that was less than the pre-existing condition period under the new plan (this period cannot be greater than 12 months), your prior months of coverage would apply to the pre-existing condition exclusion waiting period. I hope this helps. If not, please let me know what your dates of coverage under your prior plan were, the date of coverage under your new plan and the definition of the pre-existing condition exclusion period under your new plan and I will try to help you determine when and if the pre-exisitng condition clause applies under your new plan.



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