Mutuelle problem

[stan]

I have been having problems with my mutuelle, which I have subscibed to for the last 10 months since moving here. The first problem I noticed was when I went to collect my monthly prescription from the pharmacy, to be told that my mutuelle had not paid their part for several months.

I contacted my mutuelle by email, in my best French, and they rectified the situation directlly with the pharmacy, and apologised.

I then contacted the mutuelle again as I had not received any refund for the last 2 appointments with my medecin (only 7 euros 50c direct from CPAM for one appointment). They sent me an email regarding the situtation, which I do not really understand. I get the impression they wish me to do their work for them, and to take the 80 euros a month cotisations for myself and my wife.

The reply is as folows.... Nous n'avons pas réceptionné la demande de remboursement concernant la consultation du 23/11/2010.

Nous vous invitons donc à nous adresser le décompte de prestations de la CPAM correspondant.

Concernant

la consultation du 21/02/2011, cette dernière a bien été transmise par

télétransmission, et a fait l'objet d'une prise en charge à 100% du TC

par votre CPAM.

De ce fait, nous n'avons donc plus à intervenir.

I am not sure if the fault lies with me, CPAM or the mutuelle. Any advice? Many thanks.

[mint]

Do you have the words tiers payant on your cards?

If you do, then money should not need to change hands at point of use.  All the reimbursements are settled directly.

The only kind of situations when you might have to pay out first and claim afterwards is if the professional you see (eg a nurse) does not have a card reader.  In those situations, you will need to claim from CPAM.

[Sunday Driver]

They are saying that they did not receive the request for the refund concerning the consultation of 23/11/2010 and they are inviting you to send them the corresponding CPAM statement for this transaction.

As regards the consultation of 21/02/2011, they confirm that they received notification but as the cost was covered at 100% of the tariff by CPAM there is no need for any intervention on their part.

 

[stan]

Thank you sweet17 and Sunday Driver...

Sweet17- the card has tiers payant on it. I have used the card for blood tests etc, with no problem. It is only the pharmacy and doctors appointments that a problem is apparent.

Sunday Driver - the February appointment  resulted in a 7 euro 50c refund from CPAM a couple of days later, that is all. According to my cover levels with the mutuelle, I am covered up to 125% for doctors, consultants etc appointments. I am presuming the 7 euro 50c refund referred to was the refund from CPAM, but not including the refund from the mutuelle.

[Sunday Driver]

Stan

Your mutuelle are saying that the February consultation was actually covered 100% by your CPAM, so why do you presume that this 7,50€ refund relates to that consultation? What does it say on your CPAM statement?

Bear in mind that you have to pay a 0,50€ forfait per item on your monthly prescriptions so if they've been fully paid for under tiers payant (ie, no refund payable to you) then your CPAM will accumulate the forfaits and deduct them from the next non-tiers payant refund that occurs.  The standard tariff for a doctor's consulation is 23€ of which CPAM refunds you 16,10€ less a 1€ participation forfaitaire so it may be that this 7,50€ refund relates to a different treatment and takes into account deduction of the outstanding pharmacie forfaits.

As far as having a 'tiers payant' card guaranteeing payment by a mutuelle, it is down to the treatment provider as to whether or not they are prepared to accept it.  Whilst most pharmacies and medical laboratories do, many doctors and specialist consultants do not so they require payment up front.