Re: BCBS/FEP or BCBS/IL

[Guest guest]

We are also with the Federal Employee program with Blue Cross Blue

shield. I am currently working on an appeal as well. What happened

with us is that while considering the helmet for our son I called BCBS

and was told that the helmet was something that was just included in

coverage the beginning of 2006. When I told the orthotist they

couldn't believe it and called BCBS themselves. She was then told that

only in cases of craniosynostosis it is covered. After much debate

because of the lack of the money to cover the helmet, we decided our

son's health and well being were much more important. The day of the

casting the orthotist called the insurance again and specifically

asked about this diagnosis code and was again told that the federal

plan just started covering this in 2006. She even documented who she

talked to. However, after almost 2 months, I got a Explanation of

Benefits stating that they don't cover services or supplies not

specifically covered in our brochure. So, I guess you could say that

they just flat out denied it, even though they admitted to giving a

verbal ok. They also sent a letter to our orthotist stating that

verbal statements do not change the plan brochure. However, in that

same letter it gave us direction to send them more information if we

don't agree. Almost like they want us to go through all this headache

for fun! So, I am just trying to get all the information together to

send my appeal letter. Good luck!

Albrecht

In Plagiocephaly , " baby.head " <baby1smom@...> wrote:

>

> To those of you with BCBS coverage through the Federal Employee

> Program (or BCBS/IL)... we finally received word from BCBS that our

> claim for the docband was " processed at $0 " . Pretty much what we

> expected.

>

> They are requesting copies of all medical records for further

> processing...so I guess it wasn't flat-out denied, since we apparently

> still have a chance. At this point I guess it's not the official

> appeal stages.

>

> I talked to CT, and they said that I don't have to provide anything

> (letter, etc). They will send in all of their records as well as the

> Rx and med necessity letter from the neuro, who has faxed them all of

> his notes, etc, to forward as well.

>

> Just wondering if these initial claim/denial/re-claim steps were

> similar for those of you on this plan? Were you flat-out denied

> initially, or did you have this second chance before you had to

appeal?

>

> I'm also wondering about the initial claim process...I questioned why

> CT had me send it to BCBS/IL, and they said it was because everything

> had to be processed through the local BCBS state plan. In fact, our

> statement did come from BCBS/IL (we go to Oak Brook).

>

> FOR THOSE OF YOU WITH BCBS/IL....did you get reimbursement for any of

> the band cost?

>

[Guest guest]

We also have BCBS PPO for federal employee too (CA). We received the

letter of denial for the claim our son's DOC band from them today.

The reason they provided us is very brief & short:

" WE DO NOT COVER MEDICAL SERVICES DETERMINED TO BE NOT MEDICALLY

NECESSARY, OR THOSE THAT DO NOT PROVIDE THE LEVEL OF CARE

APPROPRIATE FOR YOUR CONDITION, YOU ARE RESPONSIBLE FOR THESE

CHARGES. PLEASE REFER TO THE GENERAL EXCLUSIONS SECTION OF YOUR BLUE

CROSS AND BLUE SHIELD SERVICE BENEFIT PLAN BROCHURE FOR MORE

INFORMATION. "

Before this letter of denial, we received two other letters telling

us that this claim was in process of getting more information from

the provider, so we thought it should be OK.....We did not expect

they just deny it like that!

We also called the BCBS TWICE ( In May )to check whether the DOC

band was covered by telling the insurance code CT provided us. The

answer was " YES " , but they could not tell us what is the coverage

amount. They only mentioned that CT was not a prefered provider, we

might not be able to get a full coverage....

Does anybody has BCBS PPO for federal employee get the band covered??

What should we do next? What info/pictures should we include in the

appeal letter? I would like to hear from you if you have similar

experience.

Bonnie

Mom of (8 months old, banded since 5-26-06)

> >

> > To those of you with BCBS coverage through the Federal Employee

> > Program (or BCBS/IL)... we finally received word from BCBS that

our

> > claim for the docband was " processed at $0 " . Pretty much what we

> > expected.

> >

> > They are requesting copies of all medical records for further

> > processing...so I guess it wasn't flat-out denied, since we

apparently

> > still have a chance. At this point I guess it's not the official

> > appeal stages.

> >

> > I talked to CT, and they said that I don't have to provide

anything

> > (letter, etc). They will send in all of their records as well

as the

> > Rx and med necessity letter from the neuro, who has faxed them

all of

> > his notes, etc, to forward as well.

> >

> > Just wondering if these initial claim/denial/re-claim steps were

> > similar for those of you on this plan? Were you flat-out denied

> > initially, or did you have this second chance before you had to

> appeal?

> >

> > I'm also wondering about the initial claim process...I

questioned why

> > CT had me send it to BCBS/IL, and they said it was because

everything

> > had to be processed through the local BCBS state plan. In fact,

our

> > statement did come from BCBS/IL (we go to Oak Brook).

> >

> > FOR THOSE OF YOU WITH BCBS/IL....did you get reimbursement for

any of

> > the band cost?

> >

>

[Guest guest]

We have BCBS IL--we received some coverage for the starband. We are

appealing for additional coverage bc the usual and customary amount

was 2000, well below what anyone is selling the helmets for.

Initially, we were denied coverage. Then, we went to the bcbsil

site and looked at qualifiers for coverage--a person at bcbsil

walked us through it. our son met the criteria and we sent them a

letter referencing the criteria and how he met it. We also had our

practitioner use the same language verbatim. I was told that using

the exact language was key. this link sends you to the policy

www.bcbsil.com/PDF/bluereview/august_2005.pdf under medical policy.

Good luck

> > >

> > > To those of you with BCBS coverage through the Federal Employee

> > > Program (or BCBS/IL)... we finally received word from BCBS

that

> our

> > > claim for the docband was " processed at $0 " . Pretty much what

we

> > > expected.

> > >

> > > They are requesting copies of all medical records for further

> > > processing...so I guess it wasn't flat-out denied, since we

> apparently

> > > still have a chance. At this point I guess it's not the

official

> > > appeal stages.

> > >

> > > I talked to CT, and they said that I don't have to provide

> anything

> > > (letter, etc). They will send in all of their records as well

> as the

> > > Rx and med necessity letter from the neuro, who has faxed them

> all of

> > > his notes, etc, to forward as well.

> > >

> > > Just wondering if these initial claim/denial/re-claim steps

were

> > > similar for those of you on this plan? Were you flat-out

denied

> > > initially, or did you have this second chance before you had to

> > appeal?

> > >

> > > I'm also wondering about the initial claim process...I

> questioned why

> > > CT had me send it to BCBS/IL, and they said it was because

> everything

> > > had to be processed through the local BCBS state plan. In

fact,

> our

> > > statement did come from BCBS/IL (we go to Oak Brook).

> > >

> > > FOR THOSE OF YOU WITH BCBS/IL....did you get reimbursement for

> any of

> > > the band cost?

> > >

> >

>

[Guest guest]

Below is the text of the letter:

Parents of the patient took the following repositioning actions for

four months prior to obtaining a cranial helmet:

1. Repositioned the patient's head to the opposite side of the

patient's preferred side when lying down, reclining and sitting as

follows:

a. Reconfigured crib so that only things of interest were on

opposite side of preferred side.

b. Reconfigured changing table so that patient looked to

opposite side of preferred side.

c. Repositioned patient's head while sleeping so that head

rested on opposite side of preferred side.

d. Held patient so that either was in superman position

(additional tummy time) or had to look to opposite side of preferred

side. Also used toys and other items of interest to enable patient

to look desired direction.

e. Increased time on stomach.

f. Did not let infant rest head against anything except while

sleeping and diaper changing (no laying on back, no bouncy seat, no

infant carrier, limited time in car seat; eliminated use of stroller)

g. Nursed and fed patient so that patient was forced to look to

opposite side of preferred side.

2. Learned neck exercises and performed at every changing and

additional times.

3. Repositioned crib so that patient looked away from flattened

side to view individuals in the room. Also repositioned crib toys

so that patient looked away from flattened side to view individuals

in the room.

Some of it sounds redundant, but I was told that each of 1,2and 3

had to be separately answered.

hope this is helpful.

> > >

> > > To those of you with BCBS coverage through the Federal Employee

> > > Program (or BCBS/IL)... we finally received word from BCBS

that

> our

> > > claim for the docband was " processed at $0 " . Pretty much what

we

> > > expected.

> > >

> > > They are requesting copies of all medical records for further

> > > processing...so I guess it wasn't flat-out denied, since we

> apparently

> > > still have a chance. At this point I guess it's not the

official

> > > appeal stages.

> > >

> > > I talked to CT, and they said that I don't have to provide

> anything

> > > (letter, etc). They will send in all of their records as well

> as the

> > > Rx and med necessity letter from the neuro, who has faxed them

> all of

> > > his notes, etc, to forward as well.

> > >

> > > Just wondering if these initial claim/denial/re-claim steps

were

> > > similar for those of you on this plan? Were you flat-out

denied

> > > initially, or did you have this second chance before you had to

> > appeal?

> > >

> > > I'm also wondering about the initial claim process...I

> questioned why

> > > CT had me send it to BCBS/IL, and they said it was because

> everything

> > > had to be processed through the local BCBS state plan. In

fact,

> our

> > > statement did come from BCBS/IL (we go to Oak Brook).

> > >

> > > FOR THOSE OF YOU WITH BCBS/IL....did you get reimbursement for

> any of

> > > the band cost?

> > >

> >

>

[Guest guest]

CT in Connecticut gave me a package of how to appeal a denial. I'm

sure your CT has the same info. It is very important to have doctors

write about the medical necessity of the band, that it is not simply

cosmetic. They mention BCBS a lot in the packet and having read on

this site and CT's I can see that BCBS does seem to deny coverage

initially on them and you have to appeal several times to get

coverage.

I'm appealing the amount of coverage our insurance gave, half.

> > > >

> > > > To those of you with BCBS coverage through the Federal

Employee

> > > > Program (or BCBS/IL)... we finally received word from BCBS

> that

> > our

> > > > claim for the docband was " processed at $0 " . Pretty much

what

> we

> > > > expected.

> > > >

> > > > They are requesting copies of all medical records for further

> > > > processing...so I guess it wasn't flat-out denied, since we

> > apparently

> > > > still have a chance. At this point I guess it's not the

> official

> > > > appeal stages.

> > > >

> > > > I talked to CT, and they said that I don't have to provide

> > anything

> > > > (letter, etc). They will send in all of their records as

well

> > as the

> > > > Rx and med necessity letter from the neuro, who has faxed

them

> > all of

> > > > his notes, etc, to forward as well.

> > > >

> > > > Just wondering if these initial claim/denial/re-claim steps

> were

> > > > similar for those of you on this plan? Were you flat-out

> denied

> > > > initially, or did you have this second chance before you had

to

> > > appeal?

> > > >

> > > > I'm also wondering about the initial claim process...I

> > questioned why

> > > > CT had me send it to BCBS/IL, and they said it was because

> > everything

> > > > had to be processed through the local BCBS state plan. In

> fact,

> > our

> > > > statement did come from BCBS/IL (we go to Oak Brook).

> > > >

> > > > FOR THOSE OF YOU WITH BCBS/IL....did you get reimbursement

for

> > any of

> > > > the band cost?

> > > >

> > >

> >

>