OB care spanning two plan years

[Guest CPhelps]

An employee has exhausted all flex dollars for the plan year ended 6/30/07. She has a $900 OB Care bill that started in June. She will be seen for the next several months and is making payments as time goes on. What is sufficient documentation for reimbursement for this claim? The bill turned in today states a prior balance of $835, todays charges of $225 and payment of $325. She requests a full reimbursement of her payment. Can we do that or does 'todays charges' have to be at least the $325? Thank you!

[Jacmo]

The date of service is key to everything. The provider needs to break out what services were rendered on what date, for what charges, so you can pay from the correct plan year.

[Guest CPhelps]

thank you! The advice I received earlier was to pay without regard to specific dates. This answer makes more sense and will provide the needed documentation.

[Guest Jensen]

I agree with that answer, but it may turn out to be a little tougher than it sounds. Not sure what you mean by an "OB Care bill", but based on your comment that she'll be seen for the next several months, I'm guessing that this is the flat fee charged by the doctor for all pre-natal and birth related expenses for a pregnant women. It's been my experience (both personally with my own pregnancy and professionally with requests for reimbursement) that the doctors will often just charge a flat rate that is billed to the client at the time of the first visit or periodically throughout the pregnancy. But the charges aren't necessarily connected to a specific visit or procedure. In your participant's case, she may have had her first pre-natal visit in June, at which time they billed her the full $900, though that actually covers services to be provided in the current plan year. Getting the doctor to break down the charges to coincide with a particular visit or procedure may be difficult/impossible.

Having said that, I don't have a solution for you, and I've never had to deal with a request for reimbursement for prenatal care that has spanned over two plan years, but I just wanted to give you a heads' up that you might not get as simple of an answer as you would expect it to be.

[Guest dhall111]

An employee has exhausted all flex dollars for the plan year ended 6/30/07. She has a $900 OB Care bill that started in June. She will be seen for the next several months and is making payments as time goes on. What is sufficient documentation for reimbursement for this claim? The bill turned in today states a prior balance of $835, todays charges of $225 and payment of $325. She requests a full reimbursement of her payment. Can we do that or does 'todays charges' have to be at least the $325? Thank you!

We've treated that similar to how orthodontia claims are handled:

Services can be reimbursed as services are provided. OR Reimbursement can be made as payments are being made as long as the payment is proximate to the actual service being provided (can't reimburse for old debts), OR Up-front lump sum payments can be reimbursed provided they don't apply to services beyond the current plan year. If entire treatment is paid in one up-front lump sum payment, it should be prorated over the treatment period, which may span more than one plan year