Do maternity services coverage apply to newborns?

[carefornelly]

We recently welcomed our baby daughter after a C-section delivery. We have Cigna Open Access Plus, which covers Maternity Services at 100%, including in-hospital stay during delivery.

The hospital submitted a claim for the mother, which was initially paid by Cigna at 90%. I called Cigna, and asked to reprocess. They did, and sent the remaining 10% payment to the hospital.

Few weeks later the hospital submitted a claim for the newborn. Cigna, again, paid only 90%. I called Cigna, hoping that they did the same mistake. They said that the hospital billed it as a regular hospital stay, which is covered at 90%.

I asked the hospital to send me the itemized bill. The biggest expense was Nursery (which we never used, BTW). It was charged under Revenue code 171, which is "Nursery, Newborn, Level I".

Another call to Cigna. This time I mentioned this revenue code, asking to treat the newborn stay under Maternity Services. I was told that the newborn is not the mother, that's why her stay was paid as the regular hospital stay.

How can I make Cigna to pay in full? The federal laws states the duration of stay after the C-section, and that the benefits can't be denied. The newborn claim was not denied, but was not processed the way we wanted.

[PMRNC]

Assuming your plan does cover inpatient maternity at 100%, did Cigna process the baby's charges under the mothers file? They should have. Check that first. If they didn't they need to reprocess the claim under the mothers file and then it should be 100%. It's possible Cigna had added your baby within the time frame the bill was submitted and Cigna processed under the newborn rather than under the mothers file. Look at your EOB to make sure. If they DID process under the mother's file, what is the exact reason for the "non covered" or "reduced" charges? And finally I'm assuming the hospital is in your network?

I'd also research any state laws regarding balance billing for your state.

[carefornelly]

PMRNC, thank you for the reply.

1. The hospital is in the network. The hospital is in New Jersey.

2. Our plan covers Maternity Services at 100%, specifically:

Delivery Charges (i.e. global maternity fee)
Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist
Delivery - Facility (Inpatient Hospital, Birthing Center)

3. Newborn's claim was submitted after the mother's claim was processed and finalized. Newborn's claim is a separate from the mother's: had it's own reference number, the itemized bill from the hospital shows the newborn's Cigna id (BTW, how could they figure out the Cigna id if I gave it only to the pediatrician???).

What does mother's file mean? Sorry, I am not a billing specialist, just a customer, and not familiar with the terminology. How can I get the details regarding "non covered" or "reduced" charges?

Thank you for your answers.

[PMRNC]

Ok, your problem may be that they did not process the baby's charges under your file which they should have. Because of that the hospital billing was processed as a NON maternity claim and subject to the 10% coinsurance rate. Since you said the baby had an ID # that tells me they processed under the baby not you which is incorrect. I would call them up and explain that the newborn's facility charges should be processed under YOUR file and should NOT be subject to the 90% but rather 100%. Again, I'm assuming the baby and you were both in hospital at same time.

[carefornelly]

Thank you for the answers.

The baby and the mother were in the hospital at the same time.

Whom should I ask to reprocess - the hospital or Cigna? It was the hospital, who sent the claim with the baby's Cigna id. So, it sounds logical to ask the hospital to send the corrected claim with the mother's id. Or Cigna is smart enough to link the 2 claims having the same dates of service, and service date is the same as baby's birth date?

[PMRNC]

Well, Cigna really should reprocess under the mother BUT I would not be surprised if they make you have the hospital send a corrected claim. I would probably START with calling Cigna and see which they suggest. If you do have to call Cigna, tell them they must submit a "CORRECTED CLAIM" and put it as newborn charges UNDER your ID.   Incidentally usually dependents under a plan don't have ID#'s individually. The ID number is usually the plan holder's ID number. 

[cruindy]

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