re:Insurance for Pediasure

[Guest guest]

I used to work for a non profit that assisted families in trying to

get things paid by insurance when it was denied. Do you know if you

have any laws in your state regarding health insurance & special

needs kids? Under your plan, is it administered by an

employer/considered self-funded? If you don't know, ask the HR office

of the employer, they can tell you. I live in MO and we have laws

that can assist families with their insurance issues. That's why I'm

asking because all states differ,I'm up to date on KS & MO. You can

also check with your State Department of Insurance.

First, look in your plan to see what the appeal/grievance steps

are. If you need a denial letter from them first, ask for one

explaining why the Pediasure won't be covered.Then look in your

insurance plan under things that are not covered-

exclusions/limitation. See if they specifically list that they will

not cover what they consider " supplements " IE Pediasure, etc. In

their glossary, they should list the terminology of their insurance

plan-look for MEDICALLY NECESSARY-NECESSITY. Have your PCP, Endo,

whoever write a letter saying that it is MEDICALLY NECESSARY for her

to receive the Pediasure because of her medical condition. Have them

put in there what percentage of Pediasure is her main food intake.

Write your own letter of appeal,giving some medical history

background & including the letter from the doctor. DO NOT PUT IN

THERE THAT IT IS A MONETARY HARDSHIP FOR YOU.. They really don't

care. Explain what could happen if the Pediasure isn't covered-she

could have a tube put in, which would cost them more money in

surgery, dr visits, etc.. Don't make it too long or they won't read

it. Be straight to the point and include only facts and that it will

cost them more money in the long run NOT to provide it. Send it in

to appeals people certfied mail. Also, send or give a copy to the

employers' HR. Give them some background on what's been going on.

If your plan is self-funded or administered by them, they do have a

say on what gets paid and doesn't get paid... Keep in touch with the

State Dept of Insurance. If they can do anything about it and you

get another denial, you can file a grievance with them also..

Find out where your local county/state/board has an office that

provides assistance for kids who have special needs/disabilites.

They should be able to put you in touch with organizations that have

local information that might be able to help you.

Sorry this was so long and might not make alot of sense. If you

have any other questions, let me know.

Missy

Ian's mom