Guest guest Posted January 20, 2006 Report Share Posted January 20, 2006 Amy, Here is one route: Check your Summary Plan Description to see how many times you can appeal. In my case, it was 2. Once you've followed UHC's guidelines, in many states, you can request an independent review from the state insurance commission. (This is a well-kept secret.) Independent Review is supposed to be an outside committee of professionals who review the case, which is far more than UHC does. In my state, UHC will have to pay $1000 for this process. They're taking a gamble; it's still less of an expense to them than the cost of the band. Most people give up before the independent review stage. I'm just beginning independent review so I don't know if it will work but I'll keep the board informed. Good luck. in Atlanta > > Hi everyone! We just received notice that our appeal to our insurance > company (UnitedHealthCare) has been denied to cover our son's helmet. > I know that there is a lot of information available on this site in the > files on insurance help. I utilized much of it during the first appeal > which was 15 pages long. What I am wondering now is what is my next > option? Our insurance company denied on the basis that orthotic > devices just simply are not covered. > Has anyone had experience with this and been succesful? Specifically, > has anyone recently been successful in fighting a denial against > UnitedHealthCare? > Thanks for any help that you can give me. > Amy > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 20, 2006 Report Share Posted January 20, 2006 I had this same problem. I had to keep buggin my employer. I actually got a corporate level benefits person's name from my local benefit person. I then started emailing them. Since it's your husband's company and insurance it may be more difficult for you to get info - even though it shouldn't be. He needs to get involved especially with his local benefit person. They can be a big help. Someone has the wording otherwise how can they deny - that would be a good angle to take Next appeal copy the corporate benefits person and the state insurance regulation department. na, 2 1/2 yrs, DOC Grad, Tort Resolved Kiersten, 7 1/2 months, DOC 1/10/06, Tort www.thefilyaws.com > > > > > > Hi everyone! We just received notice that our appeal to our > > insurance > > > company (UnitedHealthCare) has been denied to cover our son's > > helmet. > > > I know that there is a lot of information available on this site > in > > the > > > files on insurance help. I utilized much of it during the first > > appeal > > > which was 15 pages long. What I am wondering now is what is my > > next > > > option? Our insurance company denied on the basis that orthotic > > > devices just simply are not covered. > > > Has anyone had experience with this and been succesful? > > Specifically, > > > has anyone recently been successful in fighting a denial against > > > UnitedHealthCare? > > > Thanks for any help that you can give me. > > > Amy > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 20, 2006 Report Share Posted January 20, 2006 I had this same problem. I had to keep buggin my employer. I actually got a corporate level benefits person's name from my local benefit person. I then started emailing them. Since it's your husband's company and insurance it may be more difficult for you to get info - even though it shouldn't be. He needs to get involved especially with his local benefit person. They can be a big help. Someone has the wording otherwise how can they deny - that would be a good angle to take Next appeal copy the corporate benefits person and the state insurance regulation department. na, 2 1/2 yrs, DOC Grad, Tort Resolved Kiersten, 7 1/2 months, DOC 1/10/06, Tort www.thefilyaws.com > > > > > > Hi everyone! We just received notice that our appeal to our > > insurance > > > company (UnitedHealthCare) has been denied to cover our son's > > helmet. > > > I know that there is a lot of information available on this site > in > > the > > > files on insurance help. I utilized much of it during the first > > appeal > > > which was 15 pages long. What I am wondering now is what is my > > next > > > option? Our insurance company denied on the basis that orthotic > > > devices just simply are not covered. > > > Has anyone had experience with this and been succesful? > > Specifically, > > > has anyone recently been successful in fighting a denial against > > > UnitedHealthCare? > > > Thanks for any help that you can give me. > > > Amy > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2006 Report Share Posted February 21, 2006 Marcy, I would show them the papers we have in our files and links section associated with retained scar capsules and how risky it is to leave them in. Look under the files section for Explant info. Patty > > Hi, > > I need some help in putting together information for my insurance > company. They had agreed to pay for explant at Mayo, but denied it > thru Dr Feng. The difference was the capsulectomy. I can appeal it > and want good concrete information to give them. > > Thanks, Marcy > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2006 Report Share Posted February 21, 2006 Marcey, Sherry has been posting some really good stuff! . . . You should be able to put a book together just from this group. Be sure to check the archives too! Hugs, Rogene --- mkkinzy1 <mkkinzy@...> wrote: > Hi, > > I need some help in putting together information for > my insurance > company. They had agreed to pay for explant at > Mayo, but denied it > thru Dr Feng. The difference was the capsulectomy. > I can appeal it > and want good concrete information to give them. > > Thanks, Marcy > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 23, 2006 Report Share Posted March 23, 2006 Congratulations ! That's great news! And news that I am sure many women here are glad to hear, as it will give them hope for reimbursement through their insurance carriers. Thanks for letting us know! I hope you are celebrating! Patty > > Good Day Ladies!! > > Today we got a check from our insurance company. They re- imbursed us for 60% of my explant surgery...WooHoo!!!! > > The reason fo only the 60% is because Dr. Feng is out of the network. It did take some struggling to prove it was medically neccessary. > > I told my hubby, that it pays to stay diligent with out tithing. The insurance company could have strung us along for months. > > L > > > --------------------------------- > Messenger with Voice. Make PC-to-Phone Calls to the US (and 30+ countries) for 2¢/min or less. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 23, 2006 Report Share Posted March 23, 2006 , Congratulations!! I'm very glad to hear that all your hard work and diligence paid off. Sis > > Good Day Ladies!! > > Today we got a check from our insurance company. They re- imbursed us for 60% of my explant surgery...WooHoo!!!! > > The reason fo only the 60% is because Dr. Feng is out of the network. It did take some struggling to prove it was medically neccessary. > > I told my hubby, that it pays to stay diligent with out tithing. The insurance company could have strung us along for months. > > L > > > --------------------------------- > Messenger with Voice. Make PC-to-Phone Calls to the US (and 30+ countries) for 2¢/min or less. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 23, 2006 Report Share Posted March 23, 2006 Patty, I give God all the Glory, if it weren't for Him, we would be struggling. It just goes to show that God is faithful for the faithful. We were not expecting any reimbursement. The explant was worth every last penny, but getting some back is nice also. Lglory2glory1401 <glory2glory1401@...> wrote: Congratulations ! That's great news! And news that I am sure many women here are glad to hear, as it will give them hope for reimbursement through their insurance carriers. Thanks for letting us know! I hope you are celebrating!Patty>> Good Day Ladies!!> > Today we got a check from our insurance company. They re-imbursed us for 60% of my explant surgery...WooHoo!!!!> > The reason fo only the 60% is because Dr. Feng is out of the network. It did take some struggling to prove it was medically neccessary. > > I told my hubby, that it pays to stay diligent with out tithing. The insurance company could have strung us along for months.> > L> > > ---------------------------------> Messenger with Voice. Make PC-to-Phone Calls to the US (and 30+ countries) for 2¢/min or less.> Blab-away for as little as 1¢/min. Make PC-to-Phone Calls using Messenger with Voice. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 23, 2006 Report Share Posted March 23, 2006 how awsome that your insurance covered the procedure!! Congratulations. Cherie > > Good Day Ladies!! > > Today we got a check from our insurance company. They re- imbursed us for 60% of my explant surgery...WooHoo!!!! > > The reason fo only the 60% is because Dr. Feng is out of the network. It did take some struggling to prove it was medically neccessary. > > I told my hubby, that it pays to stay diligent with out tithing. The insurance company could have strung us along for months. > > L > > > --------------------------------- > Messenger with Voice. Make PC-to-Phone Calls to the US (and 30+ countries) for 2¢/min or less. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 23, 2006 Report Share Posted March 23, 2006 Wonderful ! . . . I know that will make recovery a lot easier! . . . If only all insurance companies would be so generous! It's a lot cheaper than treating sick women! Hugs, Rogene Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 24, 2006 Report Share Posted March 24, 2006 , Congrats on getting your insurance to cover some of the cost of explant. I am so happy for you and your husband. I am glad that your hardwork has paid off. I am still battling with my insurance and now waiting to hear back from them again. What burns me is that they agreed to pay for it if I had it done at Mayo Medical Center, but now they won't pay for it and say it wasn't medically necessary. Hugs, MK > > Good Day Ladies!! > > Today we got a check from our insurance company. They re- imbursed us for 60% of my explant surgery...WooHoo!!!! > > The reason fo only the 60% is because Dr. Feng is out of the network. It did take some struggling to prove it was medically neccessary. > > I told my hubby, that it pays to stay diligent with out tithing. The insurance company could have strung us along for months. > > L > > > --------------------------------- > Messenger with Voice. Make PC-to-Phone Calls to the US (and 30+ countries) for 2¢/min or less. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 4, 2006 Report Share Posted April 4, 2006 Hello rae, welcome to the group. Unfortunately the insurances are a pain to deal with. I think alot of parents go ahead and pay for the bands and then deal with the insurance later. Your son is at a really good age to be banded, but could also still benefit from repositioning him. Do you think you can do agressive repo till the insurance kicks in if you can't pay for it upfront? Good luck, and I hope they will hurry up with getting the band covered. Sandy Willow's mom Torticollis resolved Cranio Grad (Germany) > > Hi everyone, > > Mname is rae and my son needs a helmet. He is 4 months old and we > have really ood insurance...or so i am told. Aanyways, our specialist > sent my insurance a letter and a report about how its medically needed > and so forth. My insurance notified us that its going to take 4-5 > weeks for them to even review the report and at that time they will > make the decision if and how they will cover. Is this normal?? Did any > of you all have the same thing happen?? And if so do any of you have > suggestions on how to go about getting them to respond a lot faster. > Thanks for any ideas. > > rae > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 4, 2006 Report Share Posted April 4, 2006 Hi welcome to the group. Our insurance told us they would respond in 15 days. It has taken way longer. We're still waiting. I hope you don't have to wait to long. It is pretty agonizing. Although I try not to think about it too much. Let us know how things go. Haylee mom to andre doc band grad > > Hi everyone, > > Mname is rae and my son needs a helmet. He is 4 months old and we > have really ood insurance...or so i am told. Aanyways, our specialist > sent my insurance a letter and a report about how its medically needed > and so forth. My insurance notified us that its going to take 4-5 > weeks for them to even review the report and at that time they will > make the decision if and how they will cover. Is this normal?? Did any > of you all have the same thing happen?? And if so do any of you have > suggestions on how to go about getting them to respond a lot faster. > Thanks for any ideas. > > rae > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 4, 2006 Report Share Posted April 4, 2006 Hi, Welcome to the group! I'm sorry I can't help you w/any insurance questions. Hopefully someone here will be able to. I just wanted to say hi. > > Hi everyone, > > Mname is rae and my son needs a helmet. He is 4 months old and we > have really ood insurance...or so i am told. Aanyways, our specialist > sent my insurance a letter and a report about how its medically needed > and so forth. My insurance notified us that its going to take 4-5 > weeks for them to even review the report and at that time they will > make the decision if and how they will cover. Is this normal?? Did any > of you all have the same thing happen?? And if so do any of you have > suggestions on how to go about getting them to respond a lot faster. > Thanks for any ideas. > > rae > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 4, 2006 Report Share Posted April 4, 2006 Hi rae, Yes, Sandy is right. We went ahead and paid for our son's DOC band in full so we did not have to delay treatment. He has been in his band for almost four weeks now and we are just now beginning our battle. (Unfortunately for us, we are with UHC and they do not pay...we have a big fight ahead of us!) Anyway, if you do not want to delay treatment, which is vital that it is begun as early as possible for best results, I would recommend paying in-full up front (0% interest credit card was our choice!) and battling your insurance company once he's being treated. Best of luck to you, Mommy to Wes - DOC band since 3/10 - Dallas, TX In a message dated 4/3/2006 8:02:24 P.M. Central Standard Time, samipa74@... writes: Hello rae,welcome to the group. Unfortunately the insurances are a pain to deal with. I think alot of parents go ahead and pay for the bands and then deal with the insurance later. Your son is at a really good age to be banded, but could also still benefit from repositioning him. Do you think you can do agressive repo till the insurance kicks in if you can't pay for it upfront? Good luck, and I hope they will hurry up with getting the band covered.Sandy Willow's momTorticollis resolvedCranio Grad (Germany)>> Hi everyone,> > Mname is rae and my son needs a helmet. He is 4 months old and we> have really ood insurance...or so i am told. Aanyways, our specialist> sent my insurance a letter and a report about how its medically needed> and so forth. My insurance notified us that its going to take 4-5> weeks for them to even review the report and at that time they will> make the decision if and how they will cover. Is this normal?? Did any> of you all have the same thing happen?? And if so do any of you have> suggestions on how to go about getting them to respond a lot faster.> Thanks for any ideas.> > rae>For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 4, 2006 Report Share Posted April 4, 2006 Hi! I'm new to this also but I have a similiar situation. The claim is in medical review. The best way to move them along is to call everyday and try to get the same person to deal with. Hope this helps, mom to 6 months, tort and plagio, scheduled for Hanger Band 4/17 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 23, 2006 Report Share Posted May 23, 2006 Many insurance companies don't cover speech therapy regardless of the code. They should cover OT if low tone is an issue. -claudia R. , MD Attending Physician Director of Fellowship Research Pediatric Emergency Medicine Department of Emergency Medicine Children's Hospital & Research Center at Oakland 747 52nd Street Oakland, CA 94609 pager: 510 539-2514 [ ] Insurance Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old now. I received the dx with the medical coding that specifically says apraxia. According to the book " The Late Talker " its one of the 'good codes'. However, my insurance called today and said declined. Not that it matters b/c EI is doing it anyway. A SLP dx'd him with that so maybe thats why declined- the actual pediatrician didn't label him with that. I am not sure if I have questions, I just was curious b/c even though dx'd with apraxia do they decline if the good codes are entered and they just make it a pain in the butt? Ahhh, I love insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 23, 2006 Report Share Posted May 23, 2006 A friend of mine who pays claims for an insurance company said that they will almost always deny the first time around. She said most people won't fight it or appeal, when they should. If they do appeal, they have a pretty good chance of getting covered. I didn't ask her how many times it takes before success. Anyway, the insurance companies want to hang on to the money, if possible. So we have to work a little harder to convince them to give some back. [ ] Insurance Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old now. I received the dx with the medical coding that specifically says apraxia. According to the book " The Late Talker " its one of the 'good codes'. However, my insurance called today and said declined. Not that it matters b/c EI is doing it anyway. A SLP dx'd him with that so maybe thats why declined- the actual pediatrician didn't label him with that. I am not sure if I have questions, I just was curious b/c even though dx'd with apraxia do they decline if the good codes are entered and they just make it a pain in the butt? Ahhh, I love insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 I was wondering exactly what your son was declined for? I have a newly diagnosed apraxic son as well and am trying to navagate this system. Luckly he has been with EI since birth due to prematurity. Even more lucky was I when I switched EI companies to one that eagerly offered speech therapy. They diagnosed him at 25 months. Now I'm wondering how Insurance should be involved. Anyone? [ ] Insurance Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old now. I received the dx with the medical coding that specifically says apraxia. According to the book " The Late Talker " its one of the 'good codes'. However, my insurance called today and said declined. Not that it matters b/c EI is doing it anyway. A SLP dx'd him with that so maybe thats why declined- the actual pediatrician didn't label him with that. I am not sure if I have questions, I just was curious b/c even though dx'd with apraxia do they decline if the good codes are entered and they just make it a pain in the butt? Ahhh, I love insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 You should get a dr. (specialist) to diagnose and provide your insurance with a letter of medical necessity for this speech therapy. This letter will indicate that Apraxia is a medical condition that requires Speech Therapy as a treatment. It should also include the medical codes for Apraxia. 784.69 (I think). My son also needed OT for his low muscle tone (Hypotonia). " M & A Dunaj " <crankeepants@... < > t> cc: Sent by: Subject: Re: [ ] Insurance @yaho ogroups.com 05/24/2006 07:29 AM Please respond to I was wondering exactly what your son was declined for? I have a newly diagnosed apraxic son as well and am trying to navagate this system. Luckly he has been with EI since birth due to prematurity. Even more lucky was I when I switched EI companies to one that eagerly offered speech therapy. They diagnosed him at 25 months. Now I'm wondering how Insurance should be involved. Anyone? [ ] Insurance Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old now. I received the dx with the medical coding that specifically says apraxia. According to the book " The Late Talker " its one of the 'good codes'. However, my insurance called today and said declined. Not that it matters b/c EI is doing it anyway. A SLP dx'd him with that so maybe thats why declined- the actual pediatrician didn't label him with that. I am not sure if I have questions, I just was curious b/c even though dx'd with apraxia do they decline if the good codes are entered and they just make it a pain in the butt? Ahhh, I love insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 My son's pediatrician used the codes 781.3 (dyspraxia/coordination disorder - I believe an OT code) and 315.32 (mixed receptive-expressive language disorder.) She used these because we were seeking initial diagnoses at that time and we also had an OT diagnosis. The OT was very helpful and listed a bunch of codes that she and the SLP in her group found successful with insurance and these were two. I've not had a problem getting coverage (limited to $2500 per calendar year) but the kicker for me is he had a hairline skull fracture in the past. It's most likely the code 804.0 for the skull fracture that is making it easy for us. No one can tell if that is the reason for this (most likely not) but they also can't prove it isn't and my son's pediatrician was happy to add whatever codes got him services. Miche At 07:27 AM 5/24/2006, you wrote: >You should get a dr. (specialist) to diagnose and provide your insurance >with a letter of medical necessity for this speech therapy. This letter >will indicate that Apraxia is a medical condition that requires Speech >Therapy as a treatment. It should also include the medical codes for >Apraxia. 784.69 (I think). My son also needed OT for his low muscle tone >(Hypotonia). Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 You also need to read the insurance policy closely. Our insurance (Pacificare) it seems doesn't offer ST for any condition. I suspect this can be fought - but with much time and energy - you may still end up empty handed. There are other insurance companies that do cover ST - even if its only a certain # a year. So it depends. Re: [ ] Insurance @yaho ogroups.com 05/24/2006 07:29 AM Please respond to I was wondering exactly what your son was declined for? I have a newly diagnosed apraxic son as well and am trying to navagate this system. Luckly he has been with EI since birth due to prematurity. Even more lucky was I when I switched EI companies to one that eagerly offered speech therapy. They diagnosed him at 25 months. Now I'm wondering how Insurance should be involved. Anyone? [ ] Insurance Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old now. I received the dx with the medical coding that specifically says apraxia. According to the book " The Late Talker " its one of the 'good codes'. However, my insurance called today and said declined. Not that it matters b/c EI is doing it anyway. A SLP dx'd him with that so maybe thats why declined- the actual pediatrician didn't label him with that. I am not sure if I have questions, I just was curious b/c even though dx'd with apraxia do they decline if the good codes are entered and they just make it a pain in the butt? Ahhh, I love insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 The medical code 784.69 is used. I dont know if I should even bother fighting it right now b/c he is getting help through EI (3 times a week) and just started. April >From: Grassia <miche@...> >Reply- > >Subject: Re: [ ] Insurance >Date: Wed, 24 May 2006 08:06:05 -0600 > >My son's pediatrician used the codes 781.3 (dyspraxia/coordination disorder >- I believe an OT code) and 315.32 (mixed receptive-expressive language >disorder.) She used these because we were seeking initial diagnoses at >that time and we also had an OT diagnosis. The OT was very helpful and >listed a bunch of codes that she and the SLP in her group found successful >with insurance and these were two. I've not had a problem getting coverage >(limited to $2500 per calendar year) but the kicker for me is he had a >hairline skull fracture in the past. It's most likely the code 804.0 for >the skull fracture that is making it easy for us. No one can tell if that >is the reason for this (most likely not) but they also can't prove it isn't >and my son's pediatrician was happy to add whatever codes got him services. > >Miche > >At 07:27 AM 5/24/2006, you wrote: > >You should get a dr. (specialist) to diagnose and provide your insurance > >with a letter of medical necessity for this speech therapy. This letter > >will indicate that Apraxia is a medical condition that requires Speech > >Therapy as a treatment. It should also include the medical codes for > >Apraxia. 784.69 (I think). My son also needed OT for his low muscle tone > >(Hypotonia). > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 April, I would make the appeal in case you may need the private therapy after EI ends on your childs third birthday. You may want to argue the insurance company by telling them it is a medical necessity versus using educational terminology. We had this problem and I got my husband's human resource department involved in writing a letter to the insurance company stating reasons for medical necessity and asking the audiologist and other professionals to use medical terms in their reports. Only 10% fight the insurance companies on their denials! 100% win their cases after a long drawn out fight! Don't give up . . . They denied us on the code for Apraxia 784.69 claiming its developmental which we all know it's NOT, but they approved the therapy for the code for Language processing disorder 388.43. A great code to use if you have a child with apraxia is 781.3 which is " lack of muscle coordination /coordination disorder. " This shows a physical diagnosis, which is typically covered, versus a developmental diagnosis, which is typically not covered. We had Blue Cross and have a 20 session limit per year. My son has apraxia, aphasia (codes are 784.3,784.69 & 784.5) Now we are with HealthNet. Your files follow you for life. Let your PT & OT know your codes for speech/language and not to use any developmental/educational codes. (just medical necessity). all the best, Joanne Mulholland Here is an archived note regarding appeals to insurance companies: In order to get your insurance company to comply with speech therapy all evaluation and treatment reports should be stated in medical terms, not educational goals. A speech pathologist (not speech therapist) should have given you a written evaluation report stating what tests were given and the medical diagnosis for your child with a treatment plan. Your pediatrician cannot evaluate but recommend a specialist to go to for further evaluation. I would appeal the HMO and state the following: 1) a specific description of the charges being appealed, 2) the names of people contacted at the insurance company with the dates the conversations took place, 3) concise explanation of what is being requested, either a re-verification of the policy requirements or asking for an exception to the rules, in either case, a strong argument defining the position of the letter writer must be stated precisely, and 4) the anticipated result by the letter writer is clearly explained. Before writing a letter: 1) Review your policy booklet to verify if a) experimental procedures are not covered and that if the medical procedure is considered experimental. If the information is not provided, contact customer service for an answer and document your conversation with them. Call customer service twice and get two different people on the phone. This is a good test to see if they provide you with the same answer. If they don't, you should complain. Remember, you are trying to prove medical necessity. 2) If it is considered experimental, then verify that this procedure is FDA approved by visiting the FDA website http://www.fda.gov, calling them directly, or by contacting your State Insurance Department. A standard rule would be if Medicare covers the procedure, most private health plans do as well. 3) If the medical procedure is not FDA approved, then another option would be to find two articles within respected medical journals that support the use of your proposed medical treatment. Submit a copy of these two articles, along with a letter of medical necessity and total costs from your medical provider to your health plan for review. 4) If the treatment is FDA approved, then contact the health plan's Medical Director to ask why the health plan has not approved coverage for this procedure. This is where it may benefit you to befriend a nurse within the health plan and explain your situation. 5) If all of these avenues fail, consider negotiating a lower price between your medical provider and health plan. After all, your health plan wants to save money 6) Write letters to every manager, director, etc. you could find who work at the health plan until you get your " YES " . 7) Contact your Department of Insurance for additional assistance. I'm not sure what state your from, but everyone has a Office of the Commissioner of Insurance. OCI investigates every complaint it receives in order to assist you in resolving your complaint, and to determine if the insurance company is complying with all state insurance laws. Good Luck! Joanne Mulholland Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 24, 2006 Report Share Posted May 24, 2006 Oh - EI contacted them since sometimes they try to see if insurance will cover it. My son will still receive services through EI, but my insurance called to tell me that he was declined- " the state will be billed " . They are basically saying they aren't covering ST. >From: " M & A Dunaj " <crankeepants@...> >Reply- >< > >Subject: Re: [ ] Insurance >Date: Wed, 24 May 2006 07:29:06 -0400 > >I was wondering exactly what your son was declined for? I have a newly >diagnosed apraxic son as well and am trying to navagate this system. >Luckly he has been with EI since birth due to prematurity. Even more lucky >was I when I switched EI companies to one that eagerly offered speech >therapy. They diagnosed him at 25 months. Now I'm wondering how Insurance >should be involved. Anyone? > [ ] Insurance > > > > Hi everyone, my son was dx'd apraxia in March. He is almost 27mos old >now. > I received the dx with the medical coding that specifically says >apraxia. > According to the book " The Late Talker " its one of the 'good codes'. > However, my insurance called today and said declined. Not that it >matters > b/c EI is doing it anyway. Quote Link to comment Share on other sites More sharing options...
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