RE: Insurance Denial Overturned

[Guest guest]

, Thanks for this posting. I just wanted to clarify something...so who is paying for the claim, the insurance company or your husband's company? Also, why were you initially denied? We had a very similar situation with our company and would love to seek some remibursement. We have already been denied twice with the ins. co and once through the state department of health because we chose to go out of network. Our in network choices were completely inexperienced and imho unknowledgable. I would love more info about your situation.

Thanks,

Amy in NY

Logan Docband grad/ right tort

Plagiocephaly From: lovingoz@...Date: Tue, 21 Oct 2008 22:13:03 +0000Subject: Insurance Denial Overturned

I just wanted to let everyone know to keep appealing your insurance company if you are denied. Our insurance company (Blue Cross/Blue Shield) denied our first claim despite medical documentation from all our doctors, specialists, etc. We sent a second packet of new information and was denied again. At this time, we were told the insurance company would not allow us to appeal again and the decision would stand. My husband contacted his benefit department and explained the situation. We were told to send the benefit department all the packets/paperwork that we had sent to the insurance company. (Thank goodness I had made several copies of all packets sent along with the pictures of Gavin's head from beginning to end.) The benefit department met and determined we should have NOT been denied the first time around and they overturned the insurance companies decision to deny payment on our claim ($2700). The reason I am telling everyone is so they continue to file claim after claim with their insurance company even if they are denied the first or second time. It helped in our case to contact the benefit department ourselves and fill them in on what was happening. Due to denial being overturned, our insurance company (within my husband's department) will request an audit to make sure no one else has been wrongfully denied payment (S1040 code). Good luck to everyone as you deal with your own insurance companies. GriffithGavin's mom Stay organized with simple drag and drop from Windows Live Hotmail. Try it

[Guest guest]

Blue Cross/Blue Shield is paying for our claim. My husband contacted

the Benefits Rep at his company and they have the ability to review

the claim and go over their head (Blue Cross) and make them pay.

That is what happened in our case....Blue Cross will cut the check

within 30 days of the overturned verdict.

Originally, we were told by the insurance company that it is

not " medically necessary " for my son to wear the helmet due to his

plagio diagnosis. I had documentation from the oral/maxilofacial

surgeon directly staing it WAS medically necessary as well as the

Cranial Center documentation (graphs, charts, etc showing the growth

of improvement from the last 15 weeks). Still, the insurance said it

wasn't medically necessary in the second appeal. I was frustrated

because I had doctors saying it was necessary, but the insurance

company said the way our plan was written, it wasn't considered

medically necessary. They went on to tell me that now matter how

well I documented the case (and I had a ton of info for them) that

the plan was written in a way that once the code of S1040 was given,

they had no intention from the beginning to pay the claim. That is

when we contacted the Benefits Department at my husbands work and

they met a few weeks later and reviewed our case. Apparently, they

do have the right to overturn the insurance decisions and usually it

is a ton of work, but since I already had all my documentation (I

made copies before I sent everything), it was not work at all on my

part....they met and decided it should have been covered the first

time the bill was submitted.

Much luck....I know how stressful it can be dealing with the

insurance company.

Griffith

[Guest guest]

are you guys actually insured through bcbs or is your dhs company self insured with bcbs as the submitting company?

On Tue, Oct 21, 2008 at 9:38 PM, <lovingoz@...> wrote:

Blue Cross/Blue Shield is paying for our claim. My husband contacted the Benefits Rep at his company and they have the ability to review the claim and go over their head (Blue Cross) and make them pay. That is what happened in our case....Blue Cross will cut the check

within 30 days of the overturned verdict. Originally, we were told by the insurance company that it is not " medically necessary " for my son to wear the helmet due to his plagio diagnosis. I had documentation from the oral/maxilofacial

surgeon directly staing it WAS medically necessary as well as the Cranial Center documentation (graphs, charts, etc showing the growth of improvement from the last 15 weeks). Still, the insurance said it wasn't medically necessary in the second appeal. I was frustrated

because I had doctors saying it was necessary, but the insurance company said the way our plan was written, it wasn't considered medically necessary. They went on to tell me that now matter how well I documented the case (and I had a ton of info for them) that

the plan was written in a way that once the code of S1040 was given, they had no intention from the beginning to pay the claim. That is when we contacted the Benefits Department at my husbands work and they met a few weeks later and reviewed our case. Apparently, they

do have the right to overturn the insurance decisions and usually it is a ton of work, but since I already had all my documentation (I made copies before I sent everything), it was not work at all on my part....they met and decided it should have been covered the first

time the bill was submitted.Much luck....I know how stressful it can be dealing with the insurance company. Griffith -- SC SAHM to:

-12 -8½ -3½ ph-1½ -2 monthThere is no finer investment for any community than putting milk into babies.Winston Churchill

[Guest guest]

Hi ,

Thanks for sharing about your experience with your insurance

company. We are still struggling with getting Aetna to cover our DOC Bands

for our son Samson. The worst part of our situation is that they normally

do pay under our policy, but treatment must begin before 12 months of

age! As we adopted Samson at 14 months of age, they are using this as a

reason to deny the claims for the bands. Now on our second band, we have experienced

great results in my opinion. I will post before and after pictures for

the group in December when Samson has graduated ---- even though he is older

for this type of treatment, you would not believe the difference.

Anyway, I will stay after them. It seems so obvious that

an insurance company’s exposure to potential future development issues

will be so significantly reduced through the use of one of these corrective

bands, but I guess it has become their job these days to deny first and pay

later when light is shed on their decision process. Crazy.

All the best, Chris

From: Plagiocephaly

[mailto:Plagiocephaly ] On Behalf Of

Sent: Tuesday, October 21, 2008 3:13 PM

Plagiocephaly

Subject: Insurance Denial Overturned

I just wanted to let everyone know to keep

appealing your insurance

company if you are denied. Our insurance company (Blue Cross/Blue

Shield) denied our first claim despite medical documentation from all

our doctors, specialists, etc. We sent a second packet of new

information and was denied again. At this time, we were told the

insurance company would not allow us to appeal again and the decision

would stand. My husband contacted his benefit department and

explained the situation. We were told to send the benefit department

all the packets/paperwork that we had sent to the insurance company.

(Thank goodness I had made several copies of all packets sent along

with the pictures of Gavin's head from beginning to end.)

The benefit department met and determined we should have NOT been

denied the first time around and they overturned the insurance

companies decision to deny payment on our claim ($2700). The reason

I am telling everyone is so they continue to file claim after claim

with their insurance company even if they are denied the first or

second time. It helped in our case to contact the benefit department

ourselves and fill them in on what was happening. Due to denial

being overturned, our insurance company (within my husband's

department) will request an audit to make sure no one else has been

wrongfully denied payment (S1040 code).

Good luck to everyone as you deal with your own insurance companies.

Griffith

Gavin's mom