Insurance Denial!

[Guest guest]

Well, we received our first denial letter today and I'm looking for

some suggestions. Just a brief (I hope) overview of our

situation...We went to our ped about 5-6 weeks ago and asked him

about getting a referral for a helmet. He had next to no information

on helmets and had obviously never referred anyone for one before.

Hard to believe when I'm told this condition is being seen more and

more these days because of the " back to sleep " campaign. Anyway, he

did end up getting us a referral to the Cranial Facial Clinic at Loma

Hospital. By this time, my son was about 2 weeks away from his

1st birthday. When we called the clinic, the nurse told me that they

really don't do the helmets on children over a year and basically

said that she was going to tell our ped. that it was too late for

them to do anything. I called her back and said I would like to at

least have him seen and she ended up saying they would see him, but

could not see him until the first week of June, about 6 weeks away.

At this point, I started researching on the internet and found

Cranial Technologies and the DocBand. We made an appointment for the

following week with a ped. neurosurgeon that refers patients for the

DocBand, got the referral and our son was casted 5 days later. We of

course did this without insurance authorization, and just received a

letter of denial because we went " out of network. " Apparently they

would prefer we had waited another 6 weeks to be seen by Loma

just so they could tell us it was too late for them to do anything.

Since time was critical, we got things moving, knowing that we may

end up having to pay for this ourselves. It is very frustrating,

especially considering that if our pediatrician had been more

knowledgeable about treatment options, we could have started this

whole process when he was much younger and may have had time to

actually wait for an authorization.

Well, as I said, I'm looking for anyone who may have had a similar

experience who might be able to offer some suggestions. By the way,

we have BlueCross California Care, which is the Blue Cross HMO. Our

medical group was the one that denied us the referral, because they

had already referred us to Loma (for all the good that was

going to do). Apparently since we are part of an HMO, the medical

group's review board is the one that makes the decision on whether or

not to give us a referral. I called Blue Cross and they said we need

to send them a letter telling them why we feel this should not have

been denied and then they have 30 days to review it and get back to

us and our medical group. Any suggestions?

Robyn

[Guest guest]

Robyn,

I am sorry to hear that you were denied. I personally don't have any

experiences with fighting my insurance company, so I hope someone

else will chime in here. Is it possible that you can fight the

appeal on the fact that the in-network comapany (Loam ) had an

age limit on their helmets, and your son had exceeded that limit,

Therefore you had to go out of network to receive proper treatment?

Talk to the people at Cranial Tech too, they might be able to offer

some insight. I wish you luck with this, and please keep us posted.

Niki

Kaylie & Danny (STAR grads)

Phila., PA

> Well, we received our first denial letter today and I'm looking for

> some suggestions. Just a brief (I hope) overview of our

> situation...We went to our ped about 5-6 weeks ago and asked him

> about getting a referral for a helmet. He had next to no

information

> on helmets and had obviously never referred anyone for one before.

> Hard to believe when I'm told this condition is being seen more and

> more these days because of the " back to sleep " campaign. Anyway,

he

> did end up getting us a referral to the Cranial Facial Clinic at

Loma

> Hospital. By this time, my son was about 2 weeks away from

his

> 1st birthday. When we called the clinic, the nurse told me that

they

> really don't do the helmets on children over a year and basically

> said that she was going to tell our ped. that it was too late for

> them to do anything. I called her back and said I would like to at

> least have him seen and she ended up saying they would see him, but

> could not see him until the first week of June, about 6 weeks

away.

> At this point, I started researching on the internet and found

> Cranial Technologies and the DocBand. We made an appointment for

the

> following week with a ped. neurosurgeon that refers patients for

the

> DocBand, got the referral and our son was casted 5 days later. We

of

> course did this without insurance authorization, and just received

a

> letter of denial because we went " out of network. " Apparently they

> would prefer we had waited another 6 weeks to be seen by Loma

> just so they could tell us it was too late for them to do

anything.

> Since time was critical, we got things moving, knowing that we may

> end up having to pay for this ourselves. It is very frustrating,

> especially considering that if our pediatrician had been more

> knowledgeable about treatment options, we could have started this

> whole process when he was much younger and may have had time to

> actually wait for an authorization.

>

> Well, as I said, I'm looking for anyone who may have had a similar

> experience who might be able to offer some suggestions. By the

way,

> we have BlueCross California Care, which is the Blue Cross HMO.

Our

> medical group was the one that denied us the referral, because they

> had already referred us to Loma (for all the good that was

> going to do). Apparently since we are part of an HMO, the medical

> group's review board is the one that makes the decision on whether

or

> not to give us a referral. I called Blue Cross and they said we

need

> to send them a letter telling them why we feel this should not have

> been denied and then they have 30 days to review it and get back to

> us and our medical group. Any suggestions?

>

> Robyn