Re: Help! Denied by Insurance again!

[Guest guest]

I'm not an attorney but if your policy does in fact have a 600

max..you may be out of luck. The best way to fight ,if you still

want to, is to address this with your HR department since

ultimately..the policy is dictated by the client..your employer.

They pick the plans according to their budget,etc. If the employers

tells them to cover it..then they will. I know it's hard when you

know you've done the best thing for your child.

Good luck!

Mommy to Mason- Starband graduate

>

> By logging into this group over the past 3 months I know that many

of

> you have had battles with your insurance companies over paying for

> banding for plagiocephaly. I need any advice that you can give

me.

> We were first denied by BCBS of NC for our DOC band because it was

> considered cosmetic. We appealed and were denied again because

they

> say that their policy states that there is a $600 maximum benefit

on

> cranial orthotics (they will pay us $600). They also say that

under

> NC law, I cannot perform a 2nd level appeal because there is a

> specific exclusion of payment over $600 in their policy. I've hit

a

> roadblock, but do not want to give up. If we sue, is there any

chance

> of winning considering the policy exclusion? We already paid $2700

> out of pocket and my son's brachy and plagio is so severe that we

may

> need a second band. Any help would be greatly appreciated!

>

>

> , 6 months, DOC banded 7/3/06

>

[Guest guest]

We have BCBS of NC, but I have not done our appeal yet. I think it

is pretty clever actually of the insurance company because they did

all of these press releases saying they were now going to cover the

treatment of plagiocephaly. As you and I know, it is the proverbial

drop in the bucket for the cost of one or two bands, but I think the

appeals are all going to lose because it is a contractual limit. If

you read the statement in their press release, they are trying to

encourage BCBS subscribers to use the passive helmet made at Baptist

Hospital, which costs less than $600. It also does not work as

effectively as the bands and is not appropriate in some cases, but

they can say that they cover treatment. I'll let you know what I

hear when we appeal, but we fully expect to be denied.

Stacey

>

> By logging into this group over the past 3 months I know that many

of

> you have had battles with your insurance companies over paying for

> banding for plagiocephaly. I need any advice that you can give

me.

> We were first denied by BCBS of NC for our DOC band because it was

> considered cosmetic. We appealed and were denied again because

they

> say that their policy states that there is a $600 maximum benefit

on

> cranial orthotics (they will pay us $600). They also say that

under

> NC law, I cannot perform a 2nd level appeal because there is a

> specific exclusion of payment over $600 in their policy. I've hit

a

> roadblock, but do not want to give up. If we sue, is there any

chance

> of winning considering the policy exclusion? We already paid

$2700

> out of pocket and my son's brachy and plagio is so severe that we

may

> need a second band. Any help would be greatly appreciated!

>

>

> , 6 months, DOC banded 7/3/06

>

[Guest guest]

ohhh, if BCBS had sent out press releases that they would cover plagio, but their "coverage" is less than 1/4 the cost of the band, then I would use the press against them. Go to your local news consumer reporter or investigative reporter and see if they'll run a story about your situation. It's probably the only thing that will help. Good luck and let us know what happens! Cris in Houston Mom to - 8.5 months DOC Band Graduate 7/25/06

How low will we go? Check out Messenger’s low PC-to-Phone call rates.

[Guest guest]

Does anyone have experience with a "peer to peer" review in BCBS? While I was compiling all the paperwork for our appeal, I noticed in the CT papers that the BCBS had given CT an number for our Pediatrician to call for a peer to peer review if we disagreed with the initial denial.

What I am wondering is if we should bother with this step or is it most likely a waste of time?

( DOC band 7/06 Virginia)

[Guest guest]

Hey i saw in your signiture that your in va? we are too were just starting this process so im fairly new to the group. still fighting with the ins. they have now turned down two major thigns my son has medically needed, the helmet and the RSV vacine, both of which he needs, this is such a frustrating process

megan

Re: Help! Denied by Insurance again!

Does anyone have experience with a "peer to peer" review in BCBS? While I was compiling all the paperwork for our appeal, I noticed in the CT papers that the BCBS had given CT an number for our Pediatrician to call for a peer to peer review if we disagreed with the initial denial.

What I am wondering is if we should bother with this step or is it most likely a waste of time?

( DOC band 7/06 Virginia)

[Guest guest]

Are there different codes that it could be billed under? Like maybe the code for the helmet will be $600 and then the other code(s) would be covered separately?

Call the provider and see what different codes they have and what they mean.

If they are going to get you on technicalities then get them back w/ technicalities!

Jen

Mommy to 4...and 1 more!!!!

"Luli"

www.babiesonline.com/babies/j/jens5th/

[Guest guest]

I contacted the NC Insurance Commission on Tuesday concerning the BCBS

of NC $600 max lifetime benefit for cranial helmeting. They did

confirm that if the specific contract states that coverage will not

exceed a stated dollar amount that it is indisputable. It doesn't seem

fair that my tax dollars allow NC Medicaid to cover the full cost of

helmet therapy while the private insurance coverage that we also

contribute to only covers a small portion of the cost. $600 won't

even cover our gas to Charlotte for the duration of his treatment.

[Guest guest]

I am certainly not defending an insurance company, but I thought I was

told fairly recently that NC medicaid did not pay for any kind of

helmet treatment. I am also not thrilled about receiving only one

tenth of what we will spend, but I keep reading on here that UHC just

flat out denies coverage over and over again.

Also, in case anyone is interested, this is one of the places you can

read their explanation of the $600.

http://www.bcbsnc.com/providers/bluelinks/pdfs/BlueLink-V7I5.pdf

Stacey

>

> I contacted the NC Insurance Commission on Tuesday concerning the

BCBS

> of NC $600 max lifetime benefit for cranial helmeting. They did

> confirm that if the specific contract states that coverage will not

> exceed a stated dollar amount that it is indisputable. It doesn't

seem

> fair that my tax dollars allow NC Medicaid to cover the full cost of

> helmet therapy while the private insurance coverage that we also

> contribute to only covers a small portion of the cost. $600 won't

> even cover our gas to Charlotte for the duration of his treatment.

>