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The State of NJ outsources the medicaid to 5 HMO insurance companies. I was billed by an ER doctor in December for an ER visit in September. I have been trying to get the EOB from Amerigroup and they refuse. I have looked at laws and the contract between the State and the HMO, and as far as I can tell, every carrier including every HMO in the State must provide the EOB within 30 days of each claim. The State says no they don't. Now I feel like my Rights are being violated. Does anyone have this problem?

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My nephew is on NJ care and Medicare. He gets his Medicare statements but not statements from Horizon who is his medicaid insurance. Does it really matter? Everything gets paid. You owe nothing unless u have co-pays and deductables. My nephew doesn't have these.
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JamesG4Justice Mar 2022
It matters. The ER billed me $721 anyway. If I had the EOB i could have proved to him I didn't owe any money. Amerigroup refused to help me.Now I think they had to provide it, and all of them. Look at the law.
N.J. Admin. Code § 11:22-1.2 - Definitions 
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, a dental service corporation or dental plan organization authorized to issue dental plans in this State, and a prepaid prescription service organization. 

N.J. Admin. Code § 11:22-1.16 - Explanation of benefits

(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan.
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https://www.state.nj.us/humanservices/dmahs/info/resources/care/

The above link may help you navigate the NJ Medicaid system and answer some questions. Try calling Legal Aid, they may have an answer for you regarding the 'legality' of Amerigroup having to provide you with an EOB for services rendered. The laws may be different pertaining to Medicaid requirements, IDK.

Good luck.
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JamesG4Justice Mar 2022
Been down that road. made the official complaints. I have to go to court to get action. The State is not going to force any of the 5 HMO that do NJ Family care to provide the EOB. I want action. This incident has taken 3 months of my life so far. The laws are not different. The State just wont enforce them for this. THE WORD EVERY MEANS EVERY. I have read the laws, Title 10 and Title 11. and now I am starting too go through the 800 page contract between the State and Amerigroup. Think about it, without the EOB or cooperation from the HMO, doctors would have a free ride to wreck the lives to every medicaid patient in the state, by billing people who have no way to pay them, then eventually suing them for the money. The legal document is the EOB. I cant get it.
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James, send the hospital a copy of your Medicaid card. That should be all you need.
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JamesG4Justice Mar 2022
The hospital had my ID , Insurance card for Amerigroup that's the HMO, and the State benefits medicaid card. The hospital and the radiology had no problem getting paid. The ER doctors group contracted by the hospital to do the medical in the ER had trouble. Amerigroup says they received the claim same day of service, electronically i assume September 9. They claim they paid it on September 29. December 2 I received a bill for 721 from the ER doctor. I called Amerigroup and they said "there is nothing I can do the matter will remain unresolved" I have been sued by the same ER doctors group in the past for medical bills. I started to freak out. With no way to prove anything I freaked out. Then i spend the next 3 months complaining, and during this time i found out i should be getting the EOB according to the NJ Code. I am still complaining.
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James, if you are in a "capitated" plan, the state is paying a fixed amount for your care and there are no EOBs.

if I recall your previous posts, you have no income or assets and are therefore judgement proof..

Consider sending a letter to the medical practice stating that Amerigroup is your insurance carrier and any billing issues will need to be taken up with them. And that have no income or assets..

Send copies of what you write to Amerigroup and the NJ State Insurance Commission.

Conside contacting your local state representative to resolve this.
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JamesG4Justice Mar 2022
The State contracts for Amerigroup to administer NJ Family Care. That is in Title 10. The contract says Amerigroup is an HMO. Title 11 says every HMO must provide the EOB. I have done what you said, I wrote maybe 100 emails between December 2 and December 6 to comsumerlink, the doctors third party billing company, freaking out. They took the bill down and sent the infor to the doctor. Amerigroup apoligized. They blame the doctor. Who knows, no one is going to investigate for REAL answers on what exactly happened and then tell me. The point now is the EOB. All the information is on my online account with Amerigroup. The whole shebang. Everything that needs to be in an EOB Is right there. But it is not pulled together in one document known as an EOB. All they have to do os take all the information they already present and put it in an EOB document members can print, or download. Very simple. Got to ask yourself why not. What is the difference between having a lgal document one can present to a jidge versus scattered information not in printable or downloadable form. The has to be a secret reason.
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James, the "secret" reason is that it costs money to generate an EOB.

Anthem, Amerigroup's parent company has a lovely tutorial that medical professionals can use to see if they've been paid. If you Google Amerigroup EOB, you'll see it.

Why can't you print out what is shown in your online account and send that to the ER docs?
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JamesG4Justice Mar 2022
So lets say I wanted then to press charges against the doctor for mail fraud. I would need the EOB. And I think you are wrong about costing them the money. They already present all the information, exactly as it is on any EOB you would get from any insurance company. All those lines of the accounting part, all their on my account, but the providers name , is on the main page, then you click a link to get the details. It is that simple. How much really would it cost to change a few lines of code and put my name, amerigroups name and the provider name on the same page as the details of the transaction? I think Amerigroup and the State set it up as a sting operation to see if I had any money. Another law they have to follow, in the contract between the State and Amerigroup is Amerigroup has to acknowledge to the provider within 2 business days they recieved the claim. The provider claimed to me he never made a claim. But the claim was showing on my account within days of the ER visit.
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Press charges? Why on earth would you do that?

If the names are on different pages, you just print out all the pages. Or copy and paste the document into an email.
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A stupid question...did the doctor's billing office bill medicaid? We had this with a small amt nephew was billed. I called the office and found Medicaid had not been billed. I am under the impression that a doctor cannot charge a medicaid recipient. A Medicaid recipient cannot pay a doctor out if pocket unless its a co-pay or deductible.

My nephew was going to a Neurologist while he was on his guardians insurance. Once on Medicaid the Neurologist did not except Medicaid. I asked if I could pay for the visit and was told no, Drs are not allowed to except payment from Medicaid recipients. When nephew was OKd for SSD, he then received Medicare and Medicaid as his secondary. The Neurologist then took him back. I notice the Medicare Statements show a balance owed the Dr. but nephew has never been billed for it.

I really think this is a billing problem. Someone has not credited your account with the doctor if u show they were paid. If it was submitted and not paid, that is not your problem. Its up to the billing clerk to find out from the insurance company why they were not paid. I have had insurance companies call a doctor for me telling them the claim was processed and paid. They have the check info. You have a Medicaid caseworker, get him/her involved. Coding is the billing clerks problem. Its the clerks job to get the doctor his money. A coding error is not uncommon. Clerk just needs to reenter the claim with the propper code.

Ask ur caseworker if I am correct about a Dr. not being able to bill you as a Medicaid recipient. A doctor excepting Medicare and Medicaid have to except what they receive from them. There is no billing the patient for money not received.

Me, I would call the billing office and tell them as a Medicaid recipient you are not responsible for any charges. If they have not been paid by Medicaid, its up to them to find out why not. And I have asked this question from my insurance provider. Do I do the research or the billing clerk and I was told the billing clerk.

I may also change providers if this Amerigroup is not willing to call the Dr and straighten this out for you. My nephew has Horizon B/C B/S and I have B/C B/S thru my husband's union and have had no problem with them helping me. Once with fraud on an employee of the doctor's.
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