u/First-Cow8319

Hi everyone,

I’m trying to figure out what to do about a claim from my primary care in network provider. I have a PPO in California, blue shield. I have a $500 outpatient deductible for in network providers. I already met my deductible back in March, and my EOB of claims submitted after March reflect this, as well as the blueshield app. My primary care provider submitted a claim, he is my assigned physician by the ppo.(we can go to others, but $10 copay instead of $35 for assigned providers). My provider submitted a claim for the removal of a small minor cyst back of head(nothing serios, scalp) from May. The claim was approved. The doctor billed $600, and the insurance approved $236 for the visit. However, the EOB says that I’m responsible for the $236 amount as part of my insurance in network deductible. I already met my deductible. Blueshield uses a third party customer service company, Included Health. I spoke to their customer service, and they told me they can see I already met my deductible and they weren’t sure why blueshield is saying I haven’t. They sent all my info to blueshield, but they haven’t responded. They included all my EOB and the spending tracking indicating my deductible was met in March. Both the EOB and customer service confirmed the doctor is still in network and the EOB also says deductible met on top for year 2026, but they are still listing on the actual details for the claim that the $236 is a members responsibility as part of the in network deductible. I spoke to 3 customer service representatives and all them told me this is an error from blueshield, but they haven’t responded. If I call blueshield directly, the system automatically forwards me to Included Health for customer service. Included health called my doctor to ask if they can put the bill on hold while they try to fix it, but blueshield has not responded to the deductible appeal review. Any options for me? My work said maybe try calling the California department of insurance. Work hr wasn’t helpful. They just told me that my deductible is $500, but they cannot assist about the blueshield issue. This is a work provided insurance, I work for the state, and they use calpers. The called calpers, but they told me to just contact included health customers service.

Hi everyone, I have a question about an EOB I received from my insurance from a recent ankle nerve block done by my in Network pain management. I have a PPO, Blue Shield of CA, deductible has been met, I have a 20 percent coinsurance.

The EOB indicates the doctor billed for 3 items. The claim says total billed 1,319.80, blueshield paid 205.35, patient responsability $51.33, Network savings 1,063.15.

Item 1 was 734.80 billed, Surgical service, Item 2 Radiology service, he used ultrasound for the block, item 3 was billed $285. The total of the 3 items add up to 1,319.80 which is what the EOB indicates.

However, for item 3, it says Office medical J3490, billed $285., amount allowed 0, paid 0, patient responsability for that item 0. For item 3, the EOB says, In order to complete processing claim we have asked the provider the names, strength, dosage and NDC of the injection. Please return the requested information to expedite our evaluation. Do not resubmit bill. This message is for the doctor.

I know if the doctor doesn’t submit the paperwork, my contract says I am not responsible because they have a certain time period. I also know that if for some reason that medication needed prior authorization, they cannot bill me, because in network doctors are responsible to get prior authorization and cannot bill patients if they failed to do so under the benefit explanation policy.

My question is, is there any chance that the doctor submits the requested paperwork for the $285 charge, and insurance just denies it, and me becoming responsible? Or because EOB is already processed, the amount would stay as patient savings? I know if Blueshield adds a payment for that item, I will be responsible for 20 percent. I’m just not sure now concerned I should be about that message on the EOB for item 3. Thanks in advance