Dealing with newborn hospital claims can be challenging, especially when they are denied due to authorization issues. Every day, many claims for newborn care are dismissed because there is no authorization for the mother, who often doesn’t need one according to ACA guidelines. Understanding the nuances of insurance coverage for birthing stays and newborn care can help prevent these denials and ensure that your claims are processed smoothly.
Birthing Stays: What’s Covered?
Under the ACA guidelines, mother birthing stays are generally covered for 24-48 hours for natural births and 36-72 hours for cesarean sections. Despite this, claims can be denied if there is no authorization on record, even though it may not be required.
Individual vs. Family Plans
Another common issue arises when the newborn is covered under their own private insurance plan at birth. In such cases, there is no direct correlation to the mother’s insurance, especially if the mother is on a family or parent plan. This can lead to complications in processing claims, particularly when the newborn and mother have different insurance providers.
A Case Study: Resolving a Newborn Claim
One memorable case involved a newborn with an individual insurance plan while the mother was insured under a completely different company. Here’s how the issue was resolved:
Information Request: Insurance companies can request information from the hospital to process claims, but not all facilities respond promptly.
Medical Records: To address this, I had to call the facility to obtain medical records, which helped track down the mother’s insurance details.
Insurance Verification: I then contacted the mother’s insurance provider to verify her active coverage and to check if an authorization was required for her stay.
Claim Processing: With all the necessary information, we ensured that everyone was covered, and the newborn’s claim was ultimately paid.
Tips for Parents
Verify Coverage: Before delivery, verify your insurance coverage and understand what is required for both the mother and the newborn.
Communicate with Providers: Ensure that the hospital and your insurance provider have all necessary information to process claims.
Follow Up: If a claim is denied, don’t hesitate to follow up with the facility and your insurance provider to provide any missing information.
Conclusion
Navigating the complexities of newborn hospital claims can be stressful, but understanding the guidelines and being proactive can help ensure that your claims are processed without issues. By verifying coverage, communicating effectively with providers, and following up on denied claims, you can avoid unnecessary complications and focus on welcoming your new baby.
Staying informed and prepared can make a significant difference in handling newborn hospital claims and ensuring that both mother and child receive the coverage they deserve.
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