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Anyone with blue cross that has filed a grievance and succeeded in getting coverage
I filed a grievance on august 10th and will hear back on september 10th. What can i do to help improve my chances of suceeding?
I am seeking treatment for pelvic pain from an out of network provider. I have used up all 24 of my physical therapy sessions for the year but my plan states i can get more if it is medically necessary. i have called all of the physical therapists within 30 miles of my residence (which is the limit after which i can see someone out of network) and i have filed a grievance stating i need treatment from an out of network provider.
I am seeking treatment for pelvic pain from an out of network provider. I have used up all 24 of my physical therapy sessions for the year but my plan states i can get more if it is medically necessary. i have called all of the physical therapists within 30 miles of my residence (which is the limit after which i can see someone out of network) and i have filed a grievance stating i need treatment from an out of network provider.
They refuse to cover me. They said that i need to pove its a medical necessity and that i need to file my final appeal. I have to pay for treatment until i can do this. can anyone help me with the appeals process regarding proving its a medical necessity?
I found out from the insurance company that i only have one appeal left. I also found out that they wont pay for anything until i have someone who is treating me that knows my condition and proves that it is medically necessary... This means i will have to pay out of pocket and get the person to file an appeal and actually win. i feel screwed. someone please explain to me what i should be doing. I live in california if that makes any difference regarding laws and regulations.
What a lucky break to have quintby here to weigh in on this question!
From my own experience, any time you have to appeal with any kind of insurance company (medical, flood, homeowners, vehicle, whatever) you need to read the policy thoroughly. Rights of appeal and the appeals process is spelled out in the policy. As a general rule, telephone conversations are not enough. Send all your evidence in writing, and preferably by certified mail.
I've had BC/BS for a number of years and found them to be pretty reasonable - as long as their appeals process is followed. (Mutual of Omaha is the WORST!) Forget about talking to any of the customer service robots at the 800 number - you have to work your way higher up the food chain. Nothing against the customer service people, but they don't have to power to go against what the computers tell them they can do.
Just stick to the appeals procedure, stick to the facts and give it time. That reminds me, there is also usually as specified time period both the appeal to be made and for BC/BS to answer it. Read the policy. Best of luck to you. :-)
From my own experience, any time you have to appeal with any kind of insurance company (medical, flood, homeowners, vehicle, whatever) you need to read the policy thoroughly. Rights of appeal and the appeals process is spelled out in the policy. As a general rule, telephone conversations are not enough. Send all your evidence in writing, and preferably by certified mail.
I've had BC/BS for a number of years and found them to be pretty reasonable - as long as their appeals process is followed. (Mutual of Omaha is the WORST!) Forget about talking to any of the customer service robots at the 800 number - you have to work your way higher up the food chain. Nothing against the customer service people, but they don't have to power to go against what the computers tell them they can do.
Just stick to the appeals procedure, stick to the facts and give it time. That reminds me, there is also usually as specified time period both the appeal to be made and for BC/BS to answer it. Read the policy. Best of luck to you. :-)
Also would it be a good idea to see her on the side for a few visits to give her a good idea on how well she can help me? i already saw her once for the exam.
pelvic pain is an emotional monster. im 25 going on 26 and have had this horrible condition for 5.5 years now. i am pretty much at my wits end.
I will call in today. i really appreciate your contacting me. I understand it can be difficult for you. i have hydrocephalus and following my surgeries i didnt have nearly as much mental capacity as i did before for at least 3 months following the surgeries. I hope through time you continue to improve. If i have any further questions id welcome you to take a look when you have time and feel like you would like to contribute again.
Let give you a quick short answer to the first part as I'm up way too late to even concentrate on most of your reply. (I have brain damage issues) I probably won't get back on til tomorrow evening.
I didn't mean to sound as snotty as I sounded, but I'm a lawyer and that's just what comes out of me when talking about procedural issues. No, I don't think giving them the number to contact is enough because they consider it your job to bring in the facts not yours. That completely ***** I realize, but whenever insurers start talking about "medical necessity" its code for "We don't want to give you something unless you force us to. They should be willing to call but they aren't and they won't.
I suggest you ask the woman if she'd let you ghost-write for her signature a very short, typed letter that summarizes what you are sure she'd be willing to say.
Now MP, I know how stressful this is, I really do. Again, as anxious as you are to get moving again, you won't be going anywhere soon if you lose. You wouldn't have written if you weren't have last-minute misgivings about your case. Trust your gut and get a 2 day or 5 day extension if that's possible. I hesitate to suggest this but consider even telling them that you've discussed this with a lawyer (you have) and he thinks ou need more time to "augment the record". This last thing is your call though, because it could backfire. Probably better to say your uncle/nephew/cousin is in law school or business school or something. Some people see red at the mention of a lawyer - you don't need that. Take some deep breaths. As you surely know, stress increses your pain, so make an effort to focus on someone or something else. Regards, Bruce
I didn't mean to sound as snotty as I sounded, but I'm a lawyer and that's just what comes out of me when talking about procedural issues. No, I don't think giving them the number to contact is enough because they consider it your job to bring in the facts not yours. That completely ***** I realize, but whenever insurers start talking about "medical necessity" its code for "We don't want to give you something unless you force us to. They should be willing to call but they aren't and they won't.
I suggest you ask the woman if she'd let you ghost-write for her signature a very short, typed letter that summarizes what you are sure she'd be willing to say.
Now MP, I know how stressful this is, I really do. Again, as anxious as you are to get moving again, you won't be going anywhere soon if you lose. You wouldn't have written if you weren't have last-minute misgivings about your case. Trust your gut and get a 2 day or 5 day extension if that's possible. I hesitate to suggest this but consider even telling them that you've discussed this with a lawyer (you have) and he thinks ou need more time to "augment the record". This last thing is your call though, because it could backfire. Probably better to say your uncle/nephew/cousin is in law school or business school or something. Some people see red at the mention of a lawyer - you don't need that. Take some deep breaths. As you surely know, stress increses your pain, so make an effort to focus on someone or something else. Regards, Bruce
Regarding getting a letter sent i saw a woman earlier this month and she examined me. she did not write a letter but i left her number for them to contact. would this not be suffice?
"What I can't understand and what Blue Cross is also likely not to understand is why the PT who provided you the first 24 sessions has now become unsuitable for continuing to treat you if you are given the go ahead to have more than the 24 sessions allowed. "
I only used 12 for pelvic pain with that provider. I used the other 12 on something else. She has stated that she herself wont treat me further. Prior to this it was all out of pocket for all of 2010. I called all pts within 30 miles of my home and they do not do the service or feel comfortable due to lack of experience. I have seen out of network providers in the past but with very little payment from the insurance company. in 2009 for example they paid 25 dollars per visit on a bill that is 200 per visit because it is out of network. The woman i want to see now is 120 per hour. I am very close to being pain free which means id be able to go back to living a normal life and not avoiding things.
"What I can't understand and what Blue Cross is also likely not to understand is why the PT who provided you the first 24 sessions has now become unsuitable for continuing to treat you if you are given the go ahead to have more than the 24 sessions allowed. "
I only used 12 for pelvic pain with that provider. I used the other 12 on something else. She has stated that she herself wont treat me further. Prior to this it was all out of pocket for all of 2010. I called all pts within 30 miles of my home and they do not do the service or feel comfortable due to lack of experience. I have seen out of network providers in the past but with very little payment from the insurance company. in 2009 for example they paid 25 dollars per visit on a bill that is 200 per visit because it is out of network. The woman i want to see now is 120 per hour. I am very close to being pain free which means id be able to go back to living a normal life and not avoiding things.
Dear MarketPantry,
You seem to be describing 2 separate issues for a single appeal 1) Blue Cross' lack of willingness to pay for any more than 24 PT sessions 2) Blue Cross' unwillingness to approve your receipt of treatment from an out of network provider.
Ideally, you would provide factual support, not just your preferences, for each issue.
For #1 you need to demonstrate that you need more sessions due to medical necessity. However much you may think that the physician who prescribed your first 24 sessions is not fully aware of your further needs, your best odds on this issue rest in presenting a letter signed by that physician stating that he/she has RECENTLY examined you and has found that you DO need additional sessions to accomplish the medical purposes he had in prescribing the first 24 sessions.
For issue #2, I assume (but cannot really determine from what you state here) that you have been unable to locate a single PT within 30 miles who is a) willing and b) has the necessary skills to provide you with the therapy you need. What I can't understand and what Blue Cross is also likely not to understand is why the PT who provided you the first 24 sessions has now become unsuitable for continuing to treat you if you are given the go ahead to have more than the 24 sessions allowed.
It sounds to me like either your doctor or your current PT, or maybe both, have already concluded that more sessions will not bring about a better result for you. If this is true (and if it is, I cannot understand why you did not say it) check to see if your plan, like many health plans, will cover the cost of seeing another practitioner (physician or PT) for the purpose of obtaining a second and hopefully different opinion as to whether you require more sessions to improve to optimum levels.
If your Blue Cross policy allows for payment for "second opinions" you may find that your best shot at obtaining more sessions will be in finding someone who will say, unequivocally and in writing, that you need them.
Given that the 30-day limit in less than 48 hours away, consider requesting a one week or 10 day extension to provide additional information to support your appeal
Good luck!
You seem to be describing 2 separate issues for a single appeal 1) Blue Cross' lack of willingness to pay for any more than 24 PT sessions 2) Blue Cross' unwillingness to approve your receipt of treatment from an out of network provider.
Ideally, you would provide factual support, not just your preferences, for each issue.
For #1 you need to demonstrate that you need more sessions due to medical necessity. However much you may think that the physician who prescribed your first 24 sessions is not fully aware of your further needs, your best odds on this issue rest in presenting a letter signed by that physician stating that he/she has RECENTLY examined you and has found that you DO need additional sessions to accomplish the medical purposes he had in prescribing the first 24 sessions.
For issue #2, I assume (but cannot really determine from what you state here) that you have been unable to locate a single PT within 30 miles who is a) willing and b) has the necessary skills to provide you with the therapy you need. What I can't understand and what Blue Cross is also likely not to understand is why the PT who provided you the first 24 sessions has now become unsuitable for continuing to treat you if you are given the go ahead to have more than the 24 sessions allowed.
It sounds to me like either your doctor or your current PT, or maybe both, have already concluded that more sessions will not bring about a better result for you. If this is true (and if it is, I cannot understand why you did not say it) check to see if your plan, like many health plans, will cover the cost of seeing another practitioner (physician or PT) for the purpose of obtaining a second and hopefully different opinion as to whether you require more sessions to improve to optimum levels.
If your Blue Cross policy allows for payment for "second opinions" you may find that your best shot at obtaining more sessions will be in finding someone who will say, unequivocally and in writing, that you need them.
Given that the 30-day limit in less than 48 hours away, consider requesting a one week or 10 day extension to provide additional information to support your appeal
Good luck!
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