I'm actually having this battle with my OWN health insurance company Administrator (Pomco) IT is NOT common to not have the CPT codes and I've been fighting with my own insurance company for a while and even have a complaint in with the dept of labor because it's an ERISA plan. Our EOB's will have "medical services" or "surgery" or "laboratory services" rather than the darn CPT code. It's Extremely frustrating and in all my years of doing billing and working for insurance companies.. this is the ONLY carrier I've encountered this with. Ironic it's my own.
the secondary insurance asks for medical records etc to determine medical necessity.
No, I don't think THIS is uncommon, I do ped's and we have some plans with different COB models so we have been asked for records from the secondary when the primary didn't require them.
Is it true that the primary plans determine medical necessity AND determines the allowed fees? The secondary insurance then pays a portion of the %
No, I would not say that is common, each carrier might have their own criteria for determining medical necessity but it's not the "normal" to have the secondary decide.. if the primary allows, most secondary's allow, it really depends on the service. I've seen primary carriers deny genetic counseling for example and the secondary want medical necessity. It depends on the plans allowance and what their benefit plan states. If you come across a lot of these I would say your mostly dealing with ERISA plans and in those cases you want to ask the patient for a copy of their summary plan benefit. With ERISA, the patient MUST be involved with all appeals. MOST group plans are ERISA unless they are church/govt plans.