January 06, 2010,
D.S. asks from Hazlet, NJ on December 30, 2006
Does Anyone Else Have Nj Family Care?
I have my daughter in Americhoice which is part of NJ Family Care. She went to the dentist this week who referred her to an oral surgeon and an orthodontist. The oral surgeon said that there is a molar that is stuck up high in her jaw and that he will have to put a gold chain around it and the orthodontist will have to work with him to pull the tooth down and out. The surgeon pulled Nicole's baby tooth out to get this started. I went to the orthodontist today and he told me that Nicole does not qualify for braces under Americhoice. But I called Americhoice the other day and they told me that braces are covered, it just has to be pre-authorized. This ortho told me it would cost me $4,000 and I would have to pay a couple hundred dollars per month. I came home and called up Americhoice again and they again told me that braces are covered, it just needs to be preauthorized. I asked them about any prequalifications like the orthodontist was telling me about - they told me there are none. I called to make an appointment somewhere else and they told me Nicole might have to prequalify. I called Americhoice back and was again told that it just needs to be preauthorized. I am so confused!! I have Americhoice Plan C which is supposed to cover dental and orthodontics. I am so confused and frustrated because Americhoice is telling me that it needs to be preauthorized but the doctors are telling me that we have to prequalify. Has anyone else had this experience?
A.O. answers from New York on January 02, 2007
I work in the medical field in an OB/Gyn office. I would ask the dentist exactly what they mean by "prequalify". Prior authorization is done by the dentists office. They call Americhoice and give details about your daughters condition to them to determine if she will be covered. Sometimes there are conditions to what/how much will be covered. Keep calling back and forth between the office and the insurance company. Persistance pays off.
A.P. answers from New York on January 27, 2007
I work for Horizon NJ Health (another Family Care HMO, the best by the way!!). It is a violation of federal regulation for a provider to bill you and/or balance-bill you for covered services. So this whole thing about you paying x-dollars a month, FORGET IT.
#2 - contact Americhoice's member services and ask to file a formal complaint. This is, unfortunately, the fastest way to get this taken care of. State that you are on Plan C which covers orthodontics (off the top of my head I think that's right too) and a participating provider (he is par, right?) is telling you a covered service has to be paid for out of pocket, pretty much exactly what you've written.
#3 - if that doesn't work, insist that the dentist's office contact their provider representative for clarification. Also, I'm pretty sure it's the dentist's responsibility to obtain the preauth, not yours. I know HNJH members don't have to get their own auths.
A.C. answers from New York on July 27, 2007
Thats horrible I hope you got this all worked out, NJ Family care is HORRIBLE but needless to say we are not millionares so we dont count in this good'ol state of NJ so thats what we get stuck with a lousy HMO where either 80% of the doctors dont take an HMO, 10% arent taking new patiants and the other 10% are so hard to find you may have to travel an unbelieveable amout of time just to get there then you have to hope that they are good doctors that you share opinoins on. its horrible. but as long as the cost of living is threw the roof taxes go up and 13$ barly pays your rent and buys you grocerys & utilitys, I guess we will just have to addapt for one day I would love to know whatits like to wake up with a PPOE and know that if any thing every happens to my babys it would be ok becuase they can go to the doctors and get what they need with out worrie.My husband and I mine as well drop off the face of the earth becuase NJ dosent even cover adults unless your pregnant. so go ahead have 100000 million babies we will give them insures where u are lucky to find a doctor with in 45 mins from your home and chaces are if they get sick we dont cover it and as for any one in your house over 18 they can get sick and die because NJ dosent give a damn.. I am so sorry I just had to vent right now I cant even find a dentist to take my youngest who finaly has 2 teeth becuase no one takes new patieants that accept the HMO UHP! and I wont chance to any thing else becuase I got lucky to get a great pediactric doctor that I can get to with out burning a tank full of gas and he takes UHP!!! I love this state!
D.A. answers from New York on January 08, 2007
Hi D. ,
I have 4 years of dental experience. Each insurance company and each plan is different. But if your dentist is a participating provider , he/she has to accept payment from the insurance. Your insurance company would know if and what your portion would be. If its different then what the dentist is telling you , you need to report them to the insurance for fraud.Because the fees may be lower then what the dentist would like , they signed a contact with the insurance to accept a certain amount for each procedure. Hope this helps you out, good luck!!
C.B. answers from New York on December 30, 2006
L.H. answers from New York on December 30, 2006
i had amerchoice and they dont except it at alot of doctors or densit i learn this thru the year i have horizon now and they are alot better
M.T. answers from New York on January 06, 2010
yes, the doctors that you decide to put your daughters braces on has to call your insurance company to get a pre-authorization. the drs offices are just giving you the run around...they are lazy because it takes a while to sit on the phone with your insurance company to get the authorization. believe me ive worked for many specialist and this is how it works with any insurance whether its familycare or just a regular insurance company. think of it this way for example...if you need to get an MRI or Cat scan, the ordering dr's office has to call your insurance company to get authorization. hope this helps. speak with a manager!
T.D. answers from New York on January 02, 2007
Hi, D......I don't have NJ Family Care...but it sounds very confusing to me as well. To be safe, I would get the pre-authorization anyway, just in case...this way you are covered. I have my own business and it gives you a discounted fee (save up to 60% on braces), so you can check that out as well. www.everyonebenefits.com/TDosch - of course you would have to go to a dentist/orthodontist in our plan...so that is the downside if your dentist is not in it!
Also, how was your daughter diagnosed with Aspergers? I am interested because my 7 year old son exhibits what I would consider mild aspergers behaviors like hand flapping, contorted facial expressions while jumping and flapping, etc. He is in a regular school, but classified with specific learning disability to get extra services, such as one on one in the classroom help, O.T. once a week, and special reading/writing classes. No one has ever mentioned Aspergers; it is just a "gut" feeling that I have.... just interested in knowing how they diagnose that condition...if you don't mind...
Thanks for your help! :-) T. D.