I finally got the insurance company to pay for the NEOCATE

[Guest guest]

Hi all:

After 4 days of beating up the insurance company they have finally agreed to

pay for Clayton's Neocate formula. I spent 4 hours on the phone with the

insurance company on Monday getting the run around. I had applied to get the

formula covered in December (the allegedly lost the paper work) and again in

March. In march they called to deny my claim, but never gave me a claim number

or a letter so I was unable to file a grievance. Finally on Monday I had had

enough and I called up and demanded to speak to the pediatric medical

director. Of course I got 10 different people but never the medical director.

i finally found soumeone in techinical support who actually ;istened to me. I

faxed her a letter (3 pages) telling her Claytons story and the run around

that I had been getting from the insurance company. She also called my Gi Dr.

who sent her another letter of medical necessity and also explained to

her clayton's condition. Well the insurance company called me this afternoon.

THEY FINALLY GOT A CASE MANAGER FOR CLAYTON AND MEDICAL REVIEW HAS DECIDED TO

PAY FOR CLAYTONS NEOCATE. I WILL NOT HAVE TO LAY OUT ANYMORE MONEY. THE

INSURANCE COMPANY (AMERIHEALTH PERSONAL CHOICE - PART OF BLUE CROSS/BLUE

SHIELD) WILL ORDER IT AND HAVE IT DELIVERED TO ME FOR FREE!!!!!!!!!!!

I feel like a great weight has been lifted from my shoulders as we were

struggling financially to pay for the formula. The have ordered me 2 boxes to

cover me until the g-tube and nissen surgery next friday and then they will

determine how much we will need. They will also be providing clayton with a

pump . ANY SUGGESTIONS ON A PUMP FOR A 16 MONTH OLD. We are going to try to

feed him solely at night - although the way he is eating by mouth may preclude

this (NOT EATING AT ALL).

ALso we are going to try to get some type of nursing assistance to help out at

night when he first comes home on the tube as I am scared as to not knowing

what to do.

I am still in shock that they are actually going to cover the formula.

I also spent a lot of time on the phone with the state and we do not qualify

for WIC or other medical insurance at this time - mainly due to out income.

However, NJ does have a Catostophic Illness fund which will reimburse you (if

your income is less than $100,000) for up any unpaid bills that amount to 15%

of your income or more (i.e. $80,000 in income need $12,000 in bills). The

bills would include, co-pays, deductibles, mileage to the docs and hospital,

parking, formula, etc. Also it is for any consecutive 12 month period. With

all of clayton's doctors visits and hospitlizations I am sure that we have the

qualifying amount in bills so we are going to start to compile this info and

submit it.

I feel like a great weight has been lifted. I guess that sometimes

perseverance pays off - also in my letter I guess that it helped that I wrote

it on my legal letter head and my last sentence said that I would pursue any

further action that was warranted.

love,

sharon

mommy to Jake (5)-nda, and fraternal 34.5 week twins Cole (3/30/97) - nda

(reformed refluxer) and Clayton(3/30/97) (eosinophil gastroenteritis, mild

developmental delays, food allergies (milk, soy, egg, wheat) Nissen and g-tube

scheduled 8/14/97)