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

WOW!!! 2.8 Million June 2019 CA Managed Health Care * Insure Me Kevin.com  * 

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

Open Enrollment till January 15th

Click here for Special Enrollment Opportunities 

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 $$$

Historical

Blue Cross Summary 6/2011 on how Health Care Reform mandates will be complied with

Blue Cross Anthem Summary 10/22/2010

Anthem Blue Cross Fact Sheet

Sample Appeal Letter-
62 page guide - DOI Washington State

Sample Appeal Letter

eoc.complaints
Specimen EOC Evidence of Coverage - Appeals - Grievances

Denied Health Coverage?  Appeal it

Kantor & Kantor Attorneys

Milliman Waste Study


The U.S. healthcare system wastes close to three-quarters of a trillion dollars a year—and the implications are not just financial. Many of the tests, treatments, and procedures that comprise healthcare waste can expose patients to undue physical, emotional, or financial harm.  http://www.milliman.com/waste

Top 10 Wasteful Services

10 wasteful procedures health

 

Steve - when he's not updating the website outside of Open Enrollment
Steve – when he’s not updating the website outside of Open Enrollment

1989 Maytag Repairman Christmas Commercial

15 comments on “Appeal & Grievances?

  1. My Medicare Advantage plan, with United Health Care denied coverage for a home health care nurse who came to our house two or three days a week for almost four months.

    I was being treated by Wound Care at Mission Hospital in Asheville, NC. Because I live 75 miles away from them, the doctors authorized a home health nurse and had me come in one day each week and later every other week.

    It was a great service since my husband is 88 and cannot drive the 150 mile round trip and my injury was to my right ankle so I was not supposed to be driving long distances.

    I have read that Medicare Advantage plans often deny this coverage although Medicare provides it.

    Any advice for appealing this???

    • Well let’s research the issue first:

      Surgical dressing services

      Medicare Part B (Medical Insurance) covers medically necessary treatment of a surgical or surgically treated wound.

      Your costs in Original Medicare

      You pay 20% of the Medicare-approved amount for your doctor’s or other health care provider’s services. You pay a fixed Copayment for these services when you get them in a hospital outpatient setting. The Part B deductible applies. You pay nothing for the supplies. https://www.medicare.gov/coverage/surgical-dressing-services

      UHC Bulletin on Wound Care This bulletin is beyond our paygrade… Try the links above.

      Home health aide services: Medicare will pay for part-time or intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting
      skilled care
      . Skilled care includes:

      ■ Skilled nursing care
      ■ Physical therapy
      ■ Speech-language pathology services
      ■ Continuing occupational therapy, if you no longer need any of the above

      Medicare & Home Health Care # 10969

      Medicare Benefit Policy Manual

      Medstarvna.org Wound Care at Home

      Here’s an evidence of coverage for UHC, not necessarily your plan.

      Medically Necessary – means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion:
      • In accordance with Generally Accepted Standards of Medical Practice.
      Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness.
      Not mainly for your convenience or that of your doctor or other health care provider.
      • Meet, but do not exceed your medical need, are at least as beneficial as an existing and
      available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively.

      Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

      Home Health Care – Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart in Chapter 4, Section 2.1 under the heading “Home health agency care.” If you need home health care services, our plan will cover these services for you provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements, or full-time nursing care at home.

      Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Our webpage on Medical Necessity

      Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

      Prior Authorization – Approval in advance to get covered services or certain drugs that may or may not be on our drug list (formulary). Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary.

      Page 273

      Send me copies of your actual bills and the denials… It doesn’t look hopeful at this time. Did you follow the appeals procedure for UHC?

  2. I recently had an appt to establish care with a primary physician after 3 yrs without. Various tests were done to assess my current health.

    I was surprised that all were not covered as part of a well woman visit or as preventative screenings.

    A test for Hep C antibodies was covered but the Hep C detection test was not.

    Blood test for lipids and triglycerides was covered but not for other blood chemicals.

    I would suspect both were necessary to provide a health profile.

    The Dr. noticed a bulge of sorts by my naval so she ordered an Abdominal Aortic Aneurysm ultrasound which was not covered.

    The AAA test is covered under the Affordable Care Act and I met four of the risk factors for checking so why was that not considered preventative screening.

    I have filed a grievance but wonder if there’s more info I need to submit from the Doctor as to why the various tests were done.

    • We are talking about what ACA defines as preventative care. Not “establishing” care or “assessing current” health.

      Here’s what is listed as preventative care:

      healthcare.gov

      Blue Shield’s List

      Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92

      If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016 Our webpage on Preventative Care

      Medical Necessity

      Clinical Guidelines

  3. My Insurance Company requires that claims be reported within 90 days. My doctor didn’t meet the deadline, what can I do?

    • Here’s what we found in the Health Net Bronze PPO Enhanced Care:

      GENERAL PROVISIONS
      NOTICE OF CLAIM: Written notice of claim must be given to Us within 20 days after the occurrence or commencement of any covered loss, or as soon thereafter as reasonably possible

      PROOFS OF LOSS: Written proof of loss must be furnished to Us at P.O. Box 9040, Farmington, MO 636409040, in case of claim for loss for which this Policy provides any periodic payment contingent upon continuing loss, within 90 days after the end of the period of time for which claim is made; in the case of claim for any other loss, written proof of loss must be furnished within 90 days after the date of the loss. Failure to furnish such proof within the time required will not invalidate or reduce any claim if proof is furnished as soon as reasonably possible. Except in the absence of legal capacity, however, We are not required to accept proofs more than one year from the time proof is otherwise required.

      ****************
      Google Research

      Investigate when claim was filed, etc. etc. with your doctor and insurance company… Nerdwallet

      **********

      what if the doctor’s office fails to file the insurance claim?
      What if the doctor files the claim after the normal 90-day insurance claim deadline?
      Do I still owe the doctor for services that would have been covered under insurance but, due to the negligence of the doctor’s office, are now unpaid?

      appeal the coverage denial. In life, the squeaky wheel gets the oil. Start squeaking.

      Obtain a copy of the late claim filed with the insurance company and a copy of the coverage denial letter. The court will be interested in seeing a letter denying an untimely claim submitted by the very doctor who assigned the debt to a bill collector.

      If you do not receive an Explanation of Benefits within 60 days of seeing a doctor, assume something is wrong and contact your insurer and the doctor’s office.

      Sam Turco Law

  4. 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

  5. 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

  6. 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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