Horizon BCBS NJ incorrect payments

[ksully]

Is anyone having any issues with Horizon BCBS not paying according to the benefits quoted?
This is for an out-of-network provider.  Benefits were quoted at 90th of fair health however claims are not paying anywhere near that.
When calling Horizon they say claims are being paid correctly off of a National Benchmark and not that of the geographical area zip code.
Is this happening to anyone else?   Do you think there is any recourse per their quoted benefits?  Anywhere can find a fee schedule for the National Benchmark?
Much appreciate any input! 

[Michele]

Out of network is so hard because most insurances give you a hard time even just answering questions.  I do not know where to get a copy of the National Benchmark.  I find that when dealing with out of network it helps if the patient actually gets involved.  Because the provider is out of network they don't seem to respond well to the provider, but the patient can either contact the insurance carrier, or go thru their personnel office if the plan is thru work.  That is where I would start.

[ksully]

Thank you.  I had tried that as well.  They just told the patient they paid the claim correctly.  Had even given them a comparison claim for another dos that actually did pay correctly and they still won't budge.

[Michele]

That is unfortunate.  I can't think of any other recourse than having the patient file an appeal or maybe a complaint.

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