What help, information & resources can you suggest to help me file an

appeal or grievance with an Insurance Company?

The process of appeals & grievances gets very technical, legal, etc.  I won’t even attempt to summarize it here.  Please follow the links below, check your policy – evidence of coverage and check the law.

Medical Procedures?

Was your procedure Medically  Necessary?

Blue Cross Clinical UM (Utilization Management) Guidelines,

Did you use the Correct MD or hospital – Provider List and

Did you Review the procedures in your actual policy, evidence of coverage?

Here’s a sample Speciment EOC Evidence of Coverage – Platinum Plan Page 151

Reasons why the Claim might be denied

Did you tell the truth on your application?
How does the Insurance Company know, if the application wasn’t filled out correctly?
Here’s where they write to your MD, before a claim is even turned in.

Billing Codes – Satire or how it really works?

Enforcement

Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –   CA Healthline 5.3.2016

Get Instant Individual & Family Quotes including Subsidy Calculation
Get Instant Individual & Family Quotes including Subsidy Calculation

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Insurance Company & Regulatory Agency Grievance Procedures & Forms

Kaiser, & Blue Shield Grievance Forms

Aetna

Blue Cross Grievance Procedures

Notice

Blue Shield – General Info.  Appeals & Grievances  PO Box 629007  El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585

CA Department of Insurance  

IMR – Independent Medical Review  

REQUEST FOR REVIEW OF CANCELLATION, RECISSION, OR NONRENEWAL OF HEALTH CARE SERVICE PLAN BENEFITS 

   

Consumer Links & Resources

Grievance procedures Free Advise.com

Insurer’s Bad Faith

Free Advice.com WHAT IS THE APPEALS AND GRIEVANCE PROCESS LIKE?

Blue Cross Specimen Policy – Sample Appeals Procedures Page 151

How to gather documents to prove your case – Small Claims Manual

Prove you never got a letter?

How to tell your story, timeline and background – actual attorney brief to the court.

How to create a TIMELINE in Word, Excel, PowerPoint

Fines against PacifiCare for improper claims handling 1/30/2008 CHFC

Health Net faces suit over refusal to cover treatments LA Times 9.13.2012

Appeal Guide – Washington State 62 pages pdf

Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$

7 comments on “Appeal & Grievances?

  1. Steve,

    My check has cleared … they should have it in there records… the last time the same thing… it was received and posted but the account was not updated …. November check has also been sent

    is it so hard to call the carrier and say… “my client is listed as cancelled yet you have received payments…can you tell me why the account is listed as cancelled or what is needed to correct the matter”

    …seems simple and fast…or would you rather wait until I search through cancelled checks to “prove” what is already known?

    • I really don’t like the telephone to deal with anything of a business matter. I much prefer email. When we approach an Insurance Company I like to follow the advice given above and get all our facts and ducks in a row first and be able to clearly express it to the Insurance Company and if need be to show clear concise emails, documents, cancelled checks, whatever is relevant to the Judge or regulatory authorities.

      The reply from the Insurance Company to your email clearly shows the point I’m trying to make.

      You will have to work with Collections to see if you can get your group reinstated. I show that we did not receive your October premiums by 10/31/18 and that is why you were cancelled.

      We have not received your November payment. I have done an audit on your account see attached.

      Collections 800-xxx-2525
      Thank you

  2. I have had many problems sense I was injured

    I have been a victim of medical malpractice

    and my lawyer also had taken advantage of me even with all my notes and complaining to everyone I could think too

    I got ignored and with all my problems

    took long to be able to feel like I can think and healed about all I am going to now

    I suffer and am in desperate need to have answers

    my medical records where compromised leaven me to suffer and

    my lawyer faild me and destroyed all hope for me

    I was double charged and now I can’t work

    waiting for disability

  3. I STARTED a POLICY ON FEB 1 EFFECTIVE DATE AND [I] CANCELLED MY POLICY DUE TO UNHAPPY SERVICES ON MARCH 2

    THEN WHY DO THEY WAIT TO TERMINATE ME UNTIL APRIL AND DO NOT GIVE ME A REFUND OF MY MONEY .

    • 1st off, you probably upset the Insurance Company, using all caps in your correspondence with them. Net Manners.com

      2nd I had to read your email several times and do major edits before I could understand your question.

      3rd – I don’t know what kind of a policy you are talking about.

      I will assume it’s individual health insurance. In our speciment policy page 22 it says that the agreement is monthly. Thus, when you cancel on March 2nd, you are covered for the rest of March and the policy can cancel the last day of March, NOT March 2nd.

      See also the explanation of Monthly premiums on page 32.

      See page 34 on the effective date of termination, which clearly says termination is the last day of the billing period that your termination was received.

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