Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 Dawn, In looking through my booklet, I found the following statement: " In some cases, MMO may determine that certain Covered Services can only be provided by Non-PPO Network Provider. If Covered Services provided by a Non-Network Provider are pre-authorized by MMO, benefits will be provided as if the Covered Services ere provided by a PPO Network Provider. To pre-authorize treatment by a Non-PPO Network Provider, your Physician must provide MMO with - the proposed treatment plan for the Covered Services - the name and location of thte proposed Non-PPO Network Provider - copies of your medical records, including diagnostic reports; and - an explanation of why the Covered Services cannot be provided by a PPO Network Provider. MMO will determine whether the Covered Services can be provided by a PPO Network Provider and that determination will be final and conclusive. MMO may elect to have you examined by a Physician of its choice and will pay for any required physical examinations. YOu and your Physician will be notified if Covered Services provided by a Non-PPO Network Provider will be covered as if they have been provided by a PPO Network Provider. If you do not receive written pre-authorization for Covered Services, benefits will be provided as descibed in the Schedule of Benefits for Covered Services received from a Non-PPO Network Provider. " The only hope I have is the original apporoval letter, which, by the way, is under a different claim number than the denial letter. Carole Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 I still think there is a possibility they are just talking about which percentage they will pay. I think they may be saying that they are not granting the in net work higher percentage. You will have to pay the bigger co pay for an out of network provider. Also check with them if they are referring to both the doc and hospital. If the hospital is in network then this only pertains to the doc and it won't be quite as bad (but not fun) to pay the additional percentage for the doc. Dawn Dr. Hess, Bowling Green, OH BPD/DS 4/27/00 www.duodenalswitch.com 267 to 165 5' 4 " size 22 to size 10 have made size goal no more high blood pressure, sore feet, or dieting! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 > I still think there is a possibility they are just talking about which > percentage they will pay. I think they may be saying that they are not > granting the in net work higher percentage. You will have to pay the bigger > co pay for an out of network provider. Also check with them if they are > referring to both the doc and hospital. If the hospital is in network then > this only pertains to the doc and it won't be quite as bad (but not fun) to > pay the additional percentage for the doc. > > Dawn Dawn, That is what I am hoping they will say because I knew that all along. I just don't understand why the last minute letter (since I was originally scheduled for 12/18/01) and why it has another claim number than the first one and why it came from a different office of Medical Mutual. It just got me so upset and depressed and now I have to wait to find out. Say a prayer for me that what you said is the case and that it will work out. If I could call Dr. Hess' office today I would because maybe they are used to getting letters like this from Med Mutual, just like they were when I got the letter with the approval for only 2 of the codes submitted. Carole (who has to pay almost 2 weeks unemployment out of 4 for COBRA)so I get to try to live on 2 weeks unemployment. Quote Link to comment Share on other sites More sharing options...
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