Re: BCBS Denial in Greenville, SC - advice needed

May 22, 2008

I have heard of ppl appealing the denial before they band on here, maybe someone will reply. I also know someone in SC who had BCBS as well and only got 1 of the 4 bands covered. BCBS SC has even LOST a lawsuit, they were sued over not paying for a cranial band and yet Hanger told us they are still refusing to pay for bands. I do believe the lawsuit info is in the files section, might be worth looking at. Personally I think BCBS SC is a JOKE! My midwifes office recently called them to find out our coverage to set up our payment plan and they told them on the phone that we are covered 100%. Well I just had a baby with them (same BCBS, same midwife) 18 mo ago and it was only covered at 80% after a $250 per person (meaning me and the baby) deductible and another $250 in hospital stay copay. As far as I know our deductible (or copay, cant remember which) went UP. So far we are completely confused. We called and they say it is covered 100%, our policy doesn't say that yet we have had ultrasound and labs submitted already, 1 lab and the ultrasound were covered 100% and one lab wasnt. I mean at this point I am wondering if your coverage varies by who the heck processes it lol.

Sorry to babble on but I have actually never had problems with BCBS until this but after reading so much on this board and from other plagio moms I now hate them. BTW the reason I didnt have problems with them for the plagio is I went over their heads. DHs company is self insured so I went right to HR and ended up going through the administration company not BCBS to get our band paid for (and we even got it covered at in network even though we used CT in Charlotte so it was out of network).

Have you called them back to ask why it was denied even though they said it was covered?

On Wed, May 21, 2008 at 9:10 PM, bjajmom <bjajmom@...> wrote:

First let me apologize for the length; I'm filling you in on our appt. today, asking some questions, and also doing some needed venting! Austin (now 6 months old) had his appointment today at Orthopedic Services, Inc. in Greenville, SC (which have the

STARband). For any of you in this area, I was very pleased with the orthotist there; he and one other orthotist specialize in STARbands and see babies all day every day with this condition. They also have the star scanner.

Austin scanned in with 15mm assymetry. That qualified as moderate/severe plagiocephaly with a touch of brachycephaly. He also was diagnosed with mild torticollis (which his Ped said he didn't have). Anyway, I had called BCBS before this appointment and

asked how a cranial remolding orthosis would be covered and they said it was covered 100% of allowable charges as long as we were in-network, pre-autorization required, and with letter of medical necessity. When the Orthotists office ran it through while we were

there today it came back that it was not covered AT ALL. I told them what BCBS had previously told me and the orthotists office said that BCBS told them that they will cover some off-brand type of generic passive helmet that is not custom nor active and come in

some generic size small, med. and large, but that was it. They don't cover anything for an active custom made orthosis. I think that is a joke. If they cover the cheapo helmet then that means they recognize the truth in the diagnosis and recognize that it

needs treatment, but won't pay for the real treatment that actually gives results??!!We are going to appeal, of course, but one main question I have to those of you that have already done this is - when a treatment

requires " pre-authorization " such as this would, and I go ahead and pay up front for the band, start Austin in the band, while we're going through the appeal process - how do you get around the ins.

co. coming back at you with the fact that you didn't get pre-cert? Obviously you can't if they deny, but I was wondering if they'll always have that to hold over your head if you go ahead with treatment and fight them in the process. Are there any needed

precautions I need to take as far as proceeding without precert but still appealing? ANY help or suggestions are welcome!Thank you,mom to Austin, 6 mos. soon to be STARband -- SC SAHM to , , , , and what should we name our baby girl?

http://www.babynames.com/namelist/9614412

May 22, 2008

I've been on the phone between BCBS and the Orthotists office all morning. BCBS is sticking to what they originally told me that it is covered with pre-authroization, letter of medical necessity, etc. but the Orthotists office continues to get different information. This is very frustrating. The orthotists office said that when they have gotten back the inital reply that BCBS gave them yesterday, they have never come back and paid in the end. When I talk to BCBS they come across like it would be no problem with needed documentation and would be 100% covered. That's a big difference in answers. Now the clock is ticking away - I think we've already missed his 6 month growth spurt - Mem. Day on Monday is going to mean that everybody's closed and will

slow us down as well. I'm thinking about messing with insurance for about a week tops and then proceeding with or without them. I don't want to lose any more precious time.

How long have pre-authorizations taken for any of you guys with BCBS? Is it completely impossible to get a pre-cert within a week or so?

Thanks,

, mom to Austin/ 6 mos. mod/severe plagio with slight brachy

Re: BCBS Denial in Greenville, SC - advice needed

I have heard of ppl appealing the denial before they band on here, maybe someone will reply. I also know someone in SC who had BCBS as well and only got 1 of the 4 bands covered. BCBS SC has even LOST a lawsuit, they were sued over not paying for a cranial band and yet Hanger told us they are still refusing to pay for bands. I do believe the lawsuit info is in the files section, might be worth looking at. Personally I think BCBS SC is a JOKE! My midwifes office recently called them to find out our coverage to set up our payment plan and they told them on the phone that we are covered 100%. Well I just had a baby with them (same BCBS, same midwife) 18 mo ago and it was only covered at 80% after a $250 per person (meaning me and the baby) deductible and another $250 in hospital stay copay. As far as I know our deductible (or copay, cant remember which) went UP. So far we are completely confused. We

called and they say it is covered 100%, our policy doesn't say that yet we have had ultrasound and labs submitted already, 1 lab and the ultrasound were covered 100% and one lab wasnt. I mean at this point I am wondering if your coverage varies by who the heck processes it lol.

Sorry to babble on but I have actually never had problems with BCBS until this but after reading so much on this board and from other plagio moms I now hate them. BTW the reason I didnt have problems with them for the plagio is I went over their heads. DHs company is self insured so I went right to HR and ended up going through the administration company not BCBS to get our band paid for (and we even got it covered at in network even though we used CT in Charlotte so it was out of network).

Have you called them back to ask why it was denied even though they said it was covered?

On Wed, May 21, 2008 at 9:10 PM, bjajmom <bjajmom (DOT) com> wrote:

First let me apologize for the length; I'm filling you in on our appt. today, asking some questions, and also doing some needed venting! Austin (now 6 months old) had his appointment today at Orthopedic Services, Inc. in Greenville, SC (which have the STARband). For any of you in this area, I was very pleased with the orthotist there; he and one other orthotist specialize in STARbands and see babies all day every day with this condition. They also have the star scanner.Austin scanned in with 15mm assymetry. That qualified as moderate/severe plagiocephaly with a touch of brachycephaly. He also was diagnosed with mild torticollis (which his Ped said he didn't have). Anyway, I had called BCBS before this appointment and asked how a cranial remolding orthosis would be covered and they said it was covered 100% of allowable charges as long as we were in-network, pre-autorization required, and with

letter of medical necessity. When the Orthotists office ran it through while we were there today it came back that it was not covered AT ALL. I told them what BCBS had previously told me and the orthotists office said that BCBS told them that they will cover some off-brand type of generic passive helmet that is not custom nor active and come in some generic size small, med. and large, but that was it. They don't cover anything for an active custom made orthosis. I think that is a joke. If they cover the cheapo helmet then that means they recognize the truth in the diagnosis and recognize that it needs treatment, but won't pay for the real treatment that actually gives results??!!We are going to appeal, of course, but one main question I have to those of you that have already done this is - when a treatment requires "pre-authorization" such as this would, and I go ahead and pay up front for

the band, start Austin in the band, while we're going through the appeal process - how do you get around the ins. co. coming back at you with the fact that you didn't get pre-cert? Obviously you can't if they deny, but I was wondering if they'll always have that to hold over your head if you go ahead with treatment and fight them in the process. Are there any needed precautions I need to take as far as proceeding without precert but still appealing? ANY help or suggestions are welcome!Thank you,mom to Austin, 6 mos. soon to be STARband-- SC SAHM to , , , , and what should we name our baby girl?http://www.babyname s.com/namelist/ 9614412

May 22, 2008

,

I am sooo sorry that you are going through this. it is very frustrating. It took us about a week and a half to get the pre-authorization from BCBS. i have the dederal PPO basic option plan. I have to pay $750 for the helmet. but that is better than $2850. Personally, i would proceed witht he helmet. In fact i would try to get in today or tomorrow and get it ordered. that way you are not wasting time. i ran into someone who fought the fight with BCBS, took about 60 days and she got the helmet paid in full. he even used an out of network provider!!!!!! So, I guess what I am saying is that if you fight long and hard you will get reimbursed. I would not wait if i were you. The first thing you need to do is get that letter on denial in your hands. Then get various letter letters of medical necessity from different providers, pictures,

articles. Then you send that all to the dept of managed care. then that may take an apeeal r 2. then if all else fails, you eather suck it up and know that you did the best for you son OR you could file a class action suite against BCBS. Good luck. Like I said, i have a friend taht went through this and fought hard...and she got the helmet covered by BCBS at an out of network provide (cranial tech).