RE: What now? BCBS ins..

[Guest guest]

Hello Sherryl,

I am sorry you are getting the run around. Can you call back and see if your policy covers it under Durable Medical Equipment? I had two choices in getting banded. I could go to Cranial Technologies get examined. They would submit his case and letter of medical necessity and then wait while BCBS reviewed it which takes about the same time frame you were given. Or I could file under Durable Medical Equipment and go to an orth place that does sell other medical equipment and have the Starband made right away. He was 6 months and I knew that if I got him banded quickly I would see the best results.I don't know about your plan but if I go out of network they still pay it is just a lower amount that is paid. Did they tell you there were places at all in network. The place that did 's band is called Medical Health Management so the name can be deceiving. You can always go ahead without approval; many places have payment plans. if I were you I would call back one more time and ask about filing it under DME.

-----Original Message-----From: Sherryl [mailto:nickandgabe@...] Sent: Tuesday, June 08, 2004 3:51 PMPlagiocephaly Subject: What now? BCBS ins..Well, we called BCBS of IL today about Zander's Plagio. First they said he was covered, no problem! We were so excited. We called back to get it in writing and the person we talked to this time had a different story.Now they say that we should go into the specialist (got our appointment changed to 6/28) and have him submit the claim to them. They will cover that charge. After that, they will have to approve/deny the banding. They said it would take 2-6 weeks to decide the claim. I'm guessing they won't cover it because it's not what they consider "medically neccessary." They also said that the orth place that we need to go to for the banding IS NOT in our network. So, doesn't that mean that even if they do decide to approve our claim, that it won't be covered anyway?Do we pay the specialist or the place that does the banding? Apparently, they are a place that does braces, artificial limbs, etc...Is that where most of you go as well?I'm so confused!! What would you do in this situation? Do I have to wait for approval/denial before I can have Zander fitted? The way I look at it now, I'm having it done whether or not BCBS pays, but I really want them to pay. I don't want to have to wait another 2-6 weeks for insurance and then another month for the band to be ready. What do you all think?Thanks,SherrylMommy to Zander~4 monthsBrachy/bossing/PlagioWaiting on the drs...For more plagio info

[Guest guest]

Hi ,

Yes, we did ask about DME, which is why they originally said we

would be covered, no questions asked. Later, they said that they

would still have to approve it before letting us know. The orth

place that I mentioned is out of network, so if they approve us for

the band, BC will pay 40% rather than 80%. But, that's only if they

approve us.

So, I need to find out, if we decide to go ahead and have him banded

before BC approves us, could they deny us based on that alone?

Meaning, had they meant to approve us and then found that we went

ahead without them, they may deny anyway.

I'm going to have my dh speak more with his HR department. They

wouldn't talk to him today because of HIPPA laws, but we're going to

try to waive that. Also, I'm going to try to contact the Plastic

Surgeon's billing office and see if they have dealt with Plagio and

BC before. Hopefully that will get me somewhere.

Thanks for your help!

Sherryl

Mommy to Zander~4 months

Brachy/bossing/Plagio

Waiting on the drs...

--- In Plagiocephaly , " michelle " <MICHELLE@C...>

wrote:

> Hello Sherryl,

>

> I am sorry you are getting the run around. Can you call back and

see if

> your policy covers it under Durable Medical Equipment? I had two

choices

> in getting banded. I could go to Cranial Technologies get

> examined. They would submit his case and letter of medical

> necessity and then wait while BCBS reviewed it which takes about

the

> same time frame you were given. Or I could file under Durable

Medical

> Equipment and go to an orth place that does sell other medical

equipment

> and have the Starband made right away. He was 6 months and I knew

that

> if I got him banded quickly I would see the best results.I don't

know

> about your plan but if I go out of network they still pay it is

just a

> lower amount that is paid. Did they tell you there were places at

all

> in network. The place that did 's band is called Medical

Health

> Management so the name can be deceiving. You can always go ahead

> without approval; many places have payment plans. if I were you I

would

> call back one more time and ask about filing it under DME.

>

>

[Guest guest]

Sherryl,

I agree with what said. 's band was covered under Durable medical equipment also. Your ins should have a rate of what they cover for providers that are not in network. The place we went to was out of our network because we live in Indiana and they covered 80%. They covered 80% for all out of network providers, I believe they do have preferred providers though.

Sara & (Starband Grad 6/7/04)

[Guest guest]

Thanks Sara! Actually, BCBS only pays 80% for in network, for us at

least. Out of network, which is what our orthodist would be, is

only 40%. It stinks. It actually surprises me because BCBS has

really come through for us in a big way for everything else. This

whole thing is disappointing. Thanks for the help!

Sherryl

Mommy to Zander

Plagio/Bossing/Brachy

Waiting on Drs...

> Sherryl,

> I agree with what said. 's band was covered under

Durable

> medical equipment also. Your ins should have a rate of what they

cover for

> providers that are not in network. The place we went to was out

of our network

> because we live in Indiana and they covered 80%. They covered 80%

for all out of

> network providers, I believe they do have preferred providers

though.

>

> Sara & (Starband Grad 6/7/04)