Re: Need help with insurance appeal

[Guest guest]

Rogene, My insurance company denied my claim at first. I asked for reasons why they decided this. Many times all they want is more documentation. Then after reading their reasons, I could then submit the records they needed to prove my case. They ended up aproving my claim the second time around. However, they only paid 60% of my claim because I went out of my network for the explant. Rogene S <saxony01@...> wrote: One of our silicone sisters has been

turned down byher insurance company and needs to file an appeal.Can someone who has been through this process offer asuggestion on how to proceed?Thanks!Rogene __________________________________________________

[Guest guest]

Thanks . . . I've passed your message along.

Rogene

--- Lamse <wannabe_proverbs31@...>

wrote:

> Rogene,

>

> My insurance company denied my claim at first. I

> asked for reasons why they decided this. Many times

> all they want is more documentation. Then after

> reading their reasons, I could then submit the

> records they needed to prove my case. They ended up

> aproving my claim the second time around. However,

> they only paid 60% of my claim because I went out of

> my network for the explant.

>

>

>

> Rogene S <saxony01@...> wrote:

> One of our silicone sisters has been

> turned down by

> her insurance company and needs to file an appeal.

>

> Can someone who has been through this process offer

> a

> suggestion on how to proceed?

>

> Thanks!

>

> Rogene

>

>

>

>

> __________________________________________________

>

[Guest guest]

Thank you for the information .

My situation was a little different. We have to call our insurance company for a authorisation number. When I rang them they said I had to call back in 48 hours. When we called them they said NO. Simple as that. My partner spoke with various people at the insurance company for quite a long time explaining the situation but they were adamant that because it was due to implants it was definitely not covered. We explained that I would not get better etc etc but they would not move. I never received anything in writing.

My report states Baker III and I have read that this should be sufficient for them to pay so I thought I would appeal. I asked my Broker how I should do this and he said to write to them.

I am just unsure how or where to start. They already have three letters from doctors/specialists regarding the health issues but these didn't seem to matter.

Any ideas?

.

-- Re: Need help with insurance appeal

Thanks . . . I've passed your message along.Rogene--- Lamse <wannabe_proverbs31 >wrote:> Rogene,> > My insurance company denied my claim at first. I> asked for reasons why they decided this. Many times> all they want is more documentation. Then after> reading their reasons, I could then submit the> records they needed to prove my case. They ended up> aproving my claim the second time around. However,> they only paid 60% of my claim because I went out of> my network for the explant.> > > > Rogene S <saxony01 > wrote:> One of our silicone sisters has been> turned down by> her insurance company and needs to file an appeal.> > Can someone who has been through this process offer> a> suggestion on how to proceed?> > Thanks!> > Rogene> > > > > __________________________________________________>

[Guest guest]

,

Start with the doctor, get a letter stating: " It is a medical

necessity to have these implants removed because..................

and here you have the doctor state the reasons why it is a medical

necessity. Letters from two doctors are pretty powerful. But they

must state that it is a medical necessity. One letter can be from

the plastic surgeon.

I advise women to NEVER contact their insurance company directly as

they will almost always get a no answer.

Even if they have said no, still go ahead and get the two letters and

have the doctors submit them if you can, otherwise you send them in

with the request from the plastic surgeon for pre-authorization.

Lynda

At 12:41 PM 6/8/2006, you wrote:

>Thank you for the information .

>

>My situation was a little different. We have to call our insurance

>company for a authorisation number. When I rang them they said I

>had to call back in 48 hours. When we called them they said

>NO. Simple as that. My partner spoke with various people at the

>insurance company for quite a long time explaining the situation but

>they were adamant that because it was due to implants it was

>definitely not covered. We explained that I would not get better

>etc etc but they would not move. I never received anything in writing.

>

>My report states Baker III and I have read that this should be

>sufficient for them to pay so I thought I would appeal. I asked my

>Broker how I should do this and he said to write to them.

>

>I am just unsure how or where to start. They already have three

>letters from doctors/specialists regarding the health issues but

>these didn't seem to matter.

>Any ideas?

>.

>

>-- Re: Need help with insurance appeal

>

>

>Thanks . . . I've passed your message along.

>

>Rogene

>

>--- Lamse

><<mailto:wannabe_proverbs31%40>wannabe_proverbs31@...>

>wrote:

>

> > Rogene,

> >

> > My insurance company denied my claim at first. I

> > asked for reasons why they decided this. Many times

> > all they want is more documentation. Then after

> > reading their reasons, I could then submit the

> > records they needed to prove my case. They ended up

> > aproving my claim the second time around. However,

> > they only paid 60% of my claim because I went out of

> > my network for the explant.

> >

> >

> >

> > Rogene S <<mailto:saxony01%40>saxony01@...> wrote:

> > One of our silicone sisters has been

> > turned down by

> > her insurance company and needs to file an appeal.

> >

> > Can someone who has been through this process offer

> > a

> > suggestion on how to proceed?

> >

> > Thanks!

> >

> > Rogene

> >

> >

> >

> >

> > __________________________________________________

> >

[Guest guest]

, I'm sorry I don't have any more advice. If the your insurance company has a policy against implants, then they probably wont pay no matter what. My company on the other hand, will pay for explant if medically necessary. You might want to check with your broker about their policies on implant related illnesses. I hope they wont "black list" all your medical needs if they know you are in need of explant. Sorry, I cant help, Lambert <manditenerife1@...> wrote: Thank you for the information . My situation was a little different. We have to call our insurance company for a authorisation number. When I rang them they said I had to call back in 48 hours. When we called them they said NO. Simple as that. My partner spoke with various people at the insurance company for quite a long time explaining the situation but they were adamant that because it was due to implants it was definitely not covered. We explained that I would not get better etc etc but they would not move. I never received anything in writing. My report states Baker III and I have read that this

should be sufficient for them to pay so I thought I would appeal. I asked my Broker how I should do this and he said to write to them. I am just unsure how or where to start. They already have three letters from doctors/specialists regarding the health issues but these didn't seem to matter. Any ideas? . -- Re: Need help with insurance

appeal Thanks . . . I've passed your message along.Rogene--- Lamse <wannabe_proverbs31 >wrote:> Rogene,> > My insurance company denied my claim at first. I> asked for reasons why they decided this. Many times> all they want is more documentation. Then after> reading their reasons, I could then submit the> records they needed to prove my case. They ended up> aproving my claim the second time around. However,> they only paid 60% of my claim because I went out of> my network for the explant.> > > > Rogene S <saxony01 > wrote:> One of our silicone sisters has been> turned down by> her insurance company and needs to file an

appeal.> > Can someone who has been through this process offer> a> suggestion on how to proceed?> > Thanks!> > Rogene> > > > > __________________________________________________>

[Guest guest]

Lynda, I contacted my insurance company to see if explants were covered. They said yes, then after Dr. Feng submitted the request, they said "no". Then my husband's Human Resource manager at work, called them and they gave her a list of documents they needed to approve the request. We submitted them and a few weeks later we had a check in the mail. It was actually easier then I thought it was going to be.Lynda <coss@...> wrote: ,Start with the doctor, get a

letter stating: "It is a medical necessity to have these implants removed because..................and here you have the doctor state the reasons why it is a medical necessity. Letters from two doctors are pretty powerful. But they must state that it is a medical necessity. One letter can be from the plastic surgeon.I advise women to NEVER contact their insurance company directly as they will almost always get a no answer.Even if they have said no, still go ahead and get the two letters and have the doctors submit them if you can, otherwise you send them in with the request from the plastic surgeon for pre-authorization.LyndaAt 12:41 PM 6/8/2006, you wrote:>Thank you for the information .>>My situation was a little different. We have to call our insurance >company for a authorisation number. When I rang them they said I >had to call back in 48 hours.

When we called them they said >NO. Simple as that. My partner spoke with various people at the >insurance company for quite a long time explaining the situation but >they were adamant that because it was due to implants it was >definitely not covered. We explained that I would not get better >etc etc but they would not move. I never received anything in writing.>>My report states Baker III and I have read that this should be >sufficient for them to pay so I thought I would appeal. I asked my >Broker how I should do this and he said to write to them.>>I am just unsure how or where to start. They already have three >letters from doctors/specialists regarding the health issues but >these didn't seem to matter.>Any ideas?>.>>-- Re: Need help with insurance appeal>>>Thanks . . . I've passed your message along.>>Rogene>>--- Lamse ><<mailto:wannabe_proverbs31%40>wannabe_proverbs31 >>wrote:>> > Rogene,> >> > My insurance company denied my claim at first. I> > asked for reasons why they decided this. Many times> > all they want is more documentation. Then after> > reading their reasons, I could then submit the>

> records they needed to prove my case. They ended up> > aproving my claim the second time around. However,> > they only paid 60% of my claim because I went out of> > my network for the explant.> >> > > >> > Rogene S <<mailto:saxony01%40>saxony01 > wrote:> > One of our silicone sisters has been> > turned down by> > her insurance company and needs to file an appeal.> >> > Can someone who has been through this process offer> > a> > suggestion on how to proceed?> >> > Thanks!> >> > Rogene> >> >> >> >> > __________________________________________________> >

[Guest guest]

Good, the procedure I outlined has worked for many women, so if

anyone is having problems, I recomment they try it.

Lynda

At 12:58 PM 6/8/2006, you wrote:

>Lynda,

>

>I contacted my insurance company to see if explants were

>covered. They said yes, then after Dr. Feng submitted the request,

>they said " no " . Then my husband's Human Resource manager at work,

>called them and they gave her a list of documents they needed to

>approve the request. We submitted them and a few weeks later we had

>a check in the mail.

>

>It was actually easier then I thought it was going to be.

>

>Lynda <coss@...> wrote:

>,

>Start with the doctor, get a letter stating: " It is a medical

>necessity to have these implants removed because..................

>and here you have the doctor state the reasons why it is a medical

>necessity. Letters from two doctors are pretty powerful. But they

>must state that it is a medical necessity. One letter can be from

>the plastic surgeon.

>

>I advise women to NEVER contact their insurance company directly as

>they will almost always get a no answer.

>

>Even if they have said no, still go ahead and get the two letters and

>have the doctors submit them if you can, otherwise you send them in

>with the request from the plastic surgeon for pre-authorization.

>

>Lynda

>

>At 12:41 PM 6/8/2006, you wrote:

>

> >Thank you for the information .

> >

> >My situation was a little different. We have to call our insurance

> >company for a authorisation number. When I rang them they said I

> >had to call back in 48 hours. When we called them they said

> >NO. Simple as that. My partner spoke with various people at the

> >insurance company for quite a long time explaining the situation but

> >they were adamant that because it was due to implants it was

> >definitely not covered. We explained that I would not get better

> >etc etc but they would not move. I never received anything in writing.

> >

> >My report states Baker III and I have read that this should be

> >sufficient for them to pay so I thought I would appeal. I asked my

> >Broker how I should do this and he said to write to them.

> >

> >I am just unsure how or where to start. They already have three

> >letters from doctors/specialists regarding the health issues but

> >these didn't seem to matter.

> >Any ideas?

> >.

> >

> >-- Re: Need help with insurance appeal

> >

> >

> >Thanks . . . I've passed your message along.

> >

> >Rogene

> >

> >--- Lamse

> ><<mailto:wannabe_proverbs31%40><mailto:wannabe_proverbs31%

> 40>wannabe_proverbs31@...>

> >wrote:

> >

> > > Rogene,

> > >

> > > My insurance company denied my claim at first. I

> > > asked for reasons why they decided this. Many times

> > > all they want is more documentation. Then after

> > > reading their reasons, I could then submit the

> > > records they needed to prove my case. They ended up

> > > aproving my claim the second time around. However,

> > > they only paid 60% of my claim because I went out of

> > > my network for the explant.

> > >

> > >

> > >

> > > Rogene S

> <<mailto:saxony01%40><mailto:saxony01%40>saxony01@...>

> wrote:

> > > One of our silicone sisters has been

> > > turned down by

> > > her insurance company and needs to file an appeal.

> > >

> > > Can someone who has been through this process offer

> > > a

> > > suggestion on how to proceed?

> > >

> > > Thanks!

> > >

> > > Rogene

> > >

> > >

> > >

> > >

> > > __________________________________________________

> > >

[Guest guest]

Thank you .

They haven't black listed me yet. I paid for my explant in April and have used my card twice since then with no problems.

Does anyone know WHY Baker III is often paid out on. Is it because it refers to the capsular and not the implant. Just thought that could be why they often paid out on that issue.

Thanks

-- Re: Need help with insurance appeal

Thanks . . . I've passed your message along.Rogene--- Lamse <wannabe_proverbs31 >wrote:> Rogene,> > My insurance company denied my claim at first. I> asked for reasons why they decided this. Many times> all they want is more documentation. Then after> reading their reasons, I could then submit the> records they needed to prove my case. They ended up> aproving my claim the second time around. However,> they only paid 60% of my claim because I went out of> my network for the explant.> > > > Rogene S <saxony01 > wrote:> One of our silicone sisters has been> turned down by> her insurance company and needs to file an appeal.> > Can someone who has been through this process offer> a> suggestion on how to proceed?> > Thanks!> > Rogene> > > > > __________________________________________________>

[Guest guest]

If you are in the US, contact the insurance commissioner in your state. A

lot of times this will get an insurance company to do what the policy

states. A letter from an attorney could go a long ways as well.

Kenda

> Thank you for the information .

>

>

>

> My situation was a little different. We have to call our insurance company

> for a authorisation number. When I rang them they said I had to call back

> in 48 hours. When we called them they said NO. Simple as that. My partner

> spoke with various people at the insurance company for quite a long time

> explaining the situation but they were adamant that because it was due to

> implants it was definitely not covered. We explained that I would not get

> better etc etc but they would not move. I never received anything in

> writing.

>

>

>

> My report states Baker III and I have read that this should be sufficient

> for them to pay so I thought I would appeal. I asked my Broker how I should

> do this and he said to write to them.

>

>

>

> I am just unsure how or where to start. They already have three letters

> from doctors/specialists regarding the health issues but these didn't seem

> to matter.

>

> Any ideas?

>

> .

>

>

>

> -- Re: Need help with insurance appeal

>

>

>

> Thanks . . . I've passed your message along.

>

>

>

> Rogene

>

>

>

> --- Lamse <wannabe_proverbs31@...>

>

> wrote:

>

>

>

>> Rogene,

>

>>

>

>> My insurance company denied my claim at first. I

>

>> asked for reasons why they decided this. Many times

>

>> all they want is more documentation. Then after

>

>> reading their reasons, I could then submit the

>

>> records they needed to prove my case. They ended up

>

>> aproving my claim the second time around. However,

>

>> they only paid 60% of my claim because I went out of

>

>> my network for the explant.

>

>>

>

>>

>

>>

>

>> Rogene S <saxony01@...> wrote:

>

>> One of our silicone sisters has been

>

>> turned down by

>

>> her insurance company and needs to file an appeal.

>

>>

>

>> Can someone who has been through this process offer

>

>> a

>

>> suggestion on how to proceed?

>

>>

>

>> Thanks!

>

>>

>

>> Rogene

>

>>

>

>>

>

>>

>

>>

>

>> __________________________________________________

>

>>

[Guest guest]

Hi Kenda,

Unfortunately I am not in the States. I live in the Canary Islands, Spanish Domain.

But I think you have given me an idea.

I will speak to someone who deals with legalities and ask them to write a letter on my behalf. It shouldn't cost too much for that and its worth a try. Thank you,

.

-- Re: Need help with insurance appeal> > > > Thanks . . . I've passed your message along.> > > > Rogene> > > > --- Lamse <wannabe_proverbs31 >> > wrote:> > > >> Rogene,> >> > >> My insurance company denied my claim at first. I> >> asked for reasons why they decided this. Many times> >> all they want is more documentation. Then after> >> reading their reasons, I could then submit the> >> records they needed to prove my case. They ended up> >> aproving my claim the second time around. However,> >> they only paid 60% of my claim because I went out of> >> my network for the explant.> >> > >> > >> > >> Rogene S <saxony01 > wrote:> >> One of our silicone sisters has been> >> turned down by> >> her insurance company and needs to file an appeal.> >> > >> Can someone who has been through this process offer> >> a> >> suggestion on how to proceed?> >> > >> Thanks!> >> > >> Rogene> >> > >> > >> > >> > >> __________________________________________________> >>

[Guest guest]

Hi , They paid for my Bakers 3-4 because of pain. Lambert <manditenerife1@...> wrote: Thank you . They haven't black listed me yet. I paid for my explant in April and have used my card twice since then with no problems. Does anyone know WHY Baker III

is often paid out on. Is it because it refers to the capsular and not the implant. Just thought that could be why they often paid out on that issue. Thanks -- Re: Need help with insurance appeal Thanks . . . I've passed your message along.Rogene--- Lamse <wannabe_proverbs31 >wrote:> Rogene,> > My insurance company denied my claim at first. I> asked for reasons why they decided this. Many

times> all they want is more documentation. Then after> reading their reasons, I could then submit the> records they needed to prove my case. They ended up> aproving my claim the second time around. However,> they only paid 60% of my claim because I went out of> my network for the explant.> > > > Rogene S <saxony01 > wrote:> One of our silicone sisters has been> turned down by> her insurance company and needs to file an appeal.> > Can someone who has been through this process offer> a> suggestion on how to proceed?> > Thanks!> > Rogene> > > > > __________________________________________________>

[Guest guest]

Let me know if you have any luck.. I am in the exact same boat with you

and we have speech and o/t and sensory therapy every week.

I also have BCBS and they basically say no to everything

[ ] need help with insurance appeal

I currently have Blue Cross/Blue Shield. Under our current plan we are

only allowed 15 visits a year. I am allowed to appeal all other denied

visits (basically since Feb.) Does anyone have some suggestions on what

information I should include in my letter in order to best plead my

case. Speech visits are like a second mortage payment every month.

If I could get any additional help, it would be a great relief.

[Guest guest]

Have you considered that this may be a denial because it is the limit

in the plan your employer pays for? If that is the case, your

employer can give an over ride and authorize additional visits.

We have Premera BC which is a BCBS relative. The base plan that my

husband's employer pays for has 45 visits per year under a

" neurodevelopmental " benefit and kids under age 7 can be billed under

that benefit. (Most Premera plans cover no speech. My husband's

employer pays a bit more for a better policy.) My husband explained

to the human resources department that last year's insurance

(lumenos) had a 90 visit per year benefit and that cutting this

benefit in half greatly affects us financially. He explained that he

loved his job but he may not be able to afford to keep his job with

this benefit cut. They gave us an over ride and we get 90 visits for

this year. No guarantees that they will do it again next year.

My point is, I could've been as mad as I wanted to be at Premera but

it was my husband's employer that was at fault. The plan they chose

to pay for offered less therapy. If they were willing to pay for me,

we'd be gettin' more. So... go ahead with your appeal but also see

if the employer will give an over ride.

Kris

The Knitting Wannabe http://knittingwannabe.typepad.com

Sonny & Shear: The I’ve Got Ewe, Babe Yarn Shop

http://www.sonnyandshear.com

On Jul 24, 2007, at 11:01 AM, DAWN UHLEIN wrote:

> Let me know if you have any luck.. I am in the exact same boat with

> you

> and we have speech and o/t and sensory therapy every week.

> I also have BCBS and they basically say no to everything

>

> [ ] need help with insurance appeal

>

> I currently have Blue Cross/Blue Shield. Under our current plan we are

> only allowed 15 visits a year. I am allowed to appeal all other denied

> visits (basically since Feb.) Does anyone have some suggestions on

> what

> information I should include in my letter in order to best plead my

> case. Speech visits are like a second mortage payment every month.

> If I could get any additional help, it would be a great relief.

>

>

>

[Guest guest]

I am also in the same boat. My boys have speech and motor apraxia and sensory

processing disorder, hypotonia, and autism. They only receive 20 visits per year

and we just had our 20th visit last week for speech and only have 8 visits left

of OT. We have filed an appeal. The first one was denied and now we have filed

a second appeal with letters from my husband, the developmental pediatrician,

speech therapist, and the OT. Any other suggestions would be greatly

appreciated. We also have BC/BS. I wish I had suggestions.

Thanks, Dana

DAWN UHLEIN <duhlein@...> wrote:

Let me know if you have any luck.. I am in the exact same boat with

you

and we have speech and o/t and sensory therapy every week.

I also have BCBS and they basically say no to everything

[ ] need help with insurance appeal

I currently have Blue Cross/Blue Shield. Under our current plan we are

only allowed 15 visits a year. I am allowed to appeal all other denied

visits (basically since Feb.) Does anyone have some suggestions on what

information I should include in my letter in order to best plead my

case. Speech visits are like a second mortage payment every month.

If I could get any additional help, it would be a great relief.

Dana

and Garrett, 3 years old as of Mar 24

SCD One Year!!!!!

Celiac, ASD, Speech and Motor Apraxia, sensory processing disorder

---------------------------------

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