(No subject)

[Guest guest]

This is what to do next.

1. Read the denial letter carefully.

2. Draft a line by line response.

3. Highlight each relavent point in your medical

record.

4. In your letter, show that you do qualify based on

your medical record.

5. In your letter, show taht you qualify based on the

national standards. You have the national standards

in Rutledge's letter.

6. PRAY... this should be #1 actually.

7. Have everyone else pray, first for peace, second

for stregnth to fight, third for an outcome in your

favor.

8. Contact your state's Department of Insurance and

see if they have any legislation about denials based

on medical necessity.

9. Take your time in preparing your appeal.

10. Remember that this is your fight. If you need

something from ANYBODY, you get it, you stay on top of

it, you fight for it. Nobody else is carrying around

your weight burden but you. Never leave it up for

someone else, if you want it done, you have to do it

yourself.

I too had to fight my insurance company and I won.

www.myminigastricbypass.com

My insurance saga can be found at my obesityhelp.com

page:

http://www.obesityhelp.com/morbidobesity/profile.phtml?N=B.966919787

Insurer Info:

SummaCare, HMO

I did have major problems with SummaCare. In fact, I

had so much trouble with them that I literally blasted

them here on obesityhelp.com. Since my first post,

some things are starting to change… (or maybe not)

I was denied care three times, but here in Ohio, we

have a patient HMO dispute law and appeal process

called House Bill 4. I was approved through this law

and thank GOD for it. I did meet with SummaCare’s CEO

and Administrator Marty Hauser on December 1, 2000.

He was very professional and it looks like SummaCare

is going to start approving this surgery when it is

medically necessary. (But currently, people are still

being denied, it is so sad). Prior to me and House

Bill 4, Summa was in the habit of denying this surgery

and they did not have a specific exclusion.

If you are in Ohio and you have an insurer that has

turned you down (and there is no exclusion

specifically for gastric bypass surgery), then you

have Ohio Rights!!! House Bill 4 passed in May of

1999 and it was made law and enforced starting in May

of 2000.

In short, House Bill 4 states that if a client has a

medically necessary dispute with their HMO, the HMO

must select one of the 6 approved Independent Review

Organizations and submit the claim to them.

In addition, the HMO must pay the IRO to do the

review, which costs about $800.

Thank God I was the first one to exercise their House

Bill 4 Rights and my MGB was APPROVED.

I self-paid and now the HMO SummaCare had to reimburse

me!!!!

I had the MGB with the Wonderful Dr. Rutledge (in

Durham, NC) on 10-25-00 (http://www.clos.net)

To learn more about your House Bill 4 Rights, please

go to this web site:

http://www.ins.state.oh.us/ConsumServ/OCS/MCGuide/MC_HMO_disputes.pdf

You will need Acrobat Reader to check it out.

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