Re: New to group - need help fighting insurance!

[Guest guest]

Hi ,

If there is an exclusion in your policy they will not cover the band unless you

can get the exclusion taken out, which involves your HR department, not the

insurance company. In order to do that, we had to send official claims in to our

insurance company getting officially rejection letters and we had to appeal that

and get denied again, THEN our company we work for who we have the insurance

with allowed us to file a 3rd and final appeal to THEM, not the insurance

company, appealing our actual insurance exclusion and ask that it be removed.

And it WORKED! It was a long process (6 months at least for us.) And we finally

got reimbursed 80% of the band cost but it wasn't until months after she had

already graduated from the band. The long part was dealing with the insurance,

our HR department got the letter of appeal, changed the policy the next day, got

our claim accepted that day, and the check was in the mail within a week of

that.

I would think in order for you to have any success you would need to contact

your HR department and ask if your exclusion could be taken out of y'alls

policy. If she says that is a possibility she should give you the steps you

need to do to see that through.

Good luck!!

>

> Hello everyone!

>

> My name is and my husband and I live in the south Florida area. We

adopted our son from Taiwan in April (he was 6 months old at the time) and when

we saw him for the first time, we noticed the right back side of his head was

severely flat. Upon recommendation of our pediatrician, she sent us to a ped.

plastic surgeon who recommended we begin helmet therapy as soon as

possible...Ethan was 7 months at the time of his consultation.

>

> We were told that Ethan was a big baby (9 lbs at birth) and suffered a hernia

in his neck at birth as well. This probably contributed to the flatness, along

with laying a lot in his crib at the orphanage.

>

> I am in the beginning stages of trying to get our insurance to cover at least

some of the expense of the helmet, if not all. We have Neighborhood Health

Partnership (which is not United Health) and I have been shut down immediately

over the phone by several representatives. No " orthotics " are covered under our

plan. But, I've got to atleast try!

>

> I honestly have no idea where to begin and am feeling so frustrated.

Thankfully, Ethan is a champ and doing great with the helmet. I am just so

overwhelmed with starting this battle and am hoping someone can point me in the

right direction.

>

> Our dr. office has provided us with the head scans, a letter from the dr, and

the bills that we have paid for the Star Band.''

>

> Any help would be greatly appreciated!

>

> Thanks,

>

>

[Guest guest]

Hi

One of the things that you have to be careful of when communicating with

insurance carriers is that you are using the correct medical term for the

funding you are requesting. Generally the front line phone staff at insurance

companies do not have a medical background and they are simply reading the

definition listed on the computer.

Often once they hear the term " orthotics " they immediately associate it with

Custom Foot Orthoses or footwear which a lot of carriers have started to reduce

or eliminate funding for. Once it is determined that you are requesting for a

cranial remolding helmet then that might fall under a different category which

might have some funding for it.

One of my parents up here in Canada applied to their insurance carrier under a

`special consideration clause' and they were able to access some funding that

might not normally be available.

Good luck and be a pest.

Mike Hall

Certified Orthotist

Hamilton Health Sciences

Hamilton Ontario

Canada

>

> Hello everyone!

>

> My name is and my husband and I live in the south Florida area. We

adopted our son from Taiwan in April (he was 6 months old at the time) and when

we saw him for the first time, we noticed the right back side of his head was

severely flat. Upon recommendation of our pediatrician, she sent us to a ped.

plastic surgeon who recommended we begin helmet therapy as soon as

possible...Ethan was 7 months at the time of his consultation.

>

> We were told that Ethan was a big baby (9 lbs at birth) and suffered a hernia

in his neck at birth as well. This probably contributed to the flatness, along

with laying a lot in his crib at the orphanage.

>

> I am in the beginning stages of trying to get our insurance to cover at least

some of the expense of the helmet, if not all. We have Neighborhood Health

Partnership (which is not United Health) and I have been shut down immediately

over the phone by several representatives. No " orthotics " are covered under our

plan. But, I've got to atleast try!

>

> I honestly have no idea where to begin and am feeling so frustrated.

Thankfully, Ethan is a champ and doing great with the helmet. I am just so

overwhelmed with starting this battle and am hoping someone can point me in the

right direction.

>

> Our dr. office has provided us with the head scans, a letter from the dr, and

the bills that we have paid for the Star Band.''

>

> Any help would be greatly appreciated!

>

> Thanks,

>

>

[Guest guest]

Here are some things to look into:

Call the insurance company and ask for how much they pay on the code S1040. Do

they still tell you it's not covered? Maybe the person you spoke to gave you

incorrect information.

The law does not allow this exclusion. (I don't know if this is true in your

case or not, but I think so.) Look it up. Try to find something that requires

insurance to cover birth defect treatments or facial deformities. Many states

have such laws, so if you look, you're likely to find something that will help

you. I took a quick look, and here's one that I think will help you. It doesn't

say they have to cover the helmet, but it does say they have to cover

reconstructive surgery.

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute & Search_St\

ring= & URL=Ch0641/SEC31094.HTM & Title=->2009->Ch0641->Section%2031094#0641.31094

There is a law saying treatment of a birth defect of a newborn child must be

covered, and in the case of an adopted child, preexisting conditions must be

covered. This leads me to think they must cover the helmet and the exclusion in

your plan is disallowed. This section is long, so you'll have to read through it

and find the applicable sections.

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute & Search_St\

ring= & URL=Ch0641/SEC31.HTM & Title=->2009->Ch0641->Section%2031#0641.31

A helmet is much cheaper than surgery for your child's severe deformational

plagiocephaly (and be sure to call it severe and deformational). In case you're

wondering, there is also a section about surgery coverage in the handbook. Let

the insurance know how much money they will save by avoiding reconstructive

surgery. Even if you have no intention of actually getting surgery, your

insurance doesn't know that.

Read through the Insurance Help documents in the " Files " section of this site.

There are many good tips.

Also, I checked out your insurers website. There is a lot of information on

there that I think will help you. They mention coverage of " durable medical

equipment, " which is the correct classification of the helmet, but through

another company. It looks like this was an insurance option that some companies

choose to offer and some don't, but I could be wrong. Here's the page with the

info. http://www.mynhp.com/member/ Look at " Advocare Health Alliance. " Does this

apply to you? If so, you do have some coverage. If not, go to your employer and

complain about the exclusion. Some employers have been able to have it removed

for the plan they offer their employees. Speak to Human Resources if you want to

try this route.

There is also mention of Durable Medical Equipment in the handbook pp. 32-33

item L. It says there is coverage up to $2,500 for 2009 with a letter of medical

necessity, which you already have. There is also a section specifically saying

custom-made orthotics to affect proper growth are covered, but it doesn't

specify for the head. Pg. 34 item EE specifies that orthotic devices for proper

growth of a child are covered.However, pg. 36 A. 8 says that cranial molding

orthotics are excluded from coverage. This is obviously bad for you and probably

why you have been denied coverage. Pg. 42 has their complaint and greivance

procedures. http://www.mynhp.com/member/forms/Member_Handbook_Small_Group.pdf

If you lose your grievances, the next step is to file a complaint with the

Agency for Health Care Administration (Subscriber Assistance Program).

http://ahca.myflorida.com/MCHQ/Consumer/SPSAP/index.shtml

They find in favor of the subscriber about 50% of the time.

The insurer's site also has an option to email them. You should do that so you

have all correspondence in writing for your records.

Off topic, you said he had damage to his neck. Are you aware of torticollis and

treatments for that?

>

> Hello everyone!

>

> My name is and my husband and I live in the south Florida area. We

adopted our son from Taiwan in April (he was 6 months old at the time) and when

we saw him for the first time, we noticed the right back side of his head was

severely flat. Upon recommendation of our pediatrician, she sent us to a ped.

plastic surgeon who recommended we begin helmet therapy as soon as

possible...Ethan was 7 months at the time of his consultation.

>

> We were told that Ethan was a big baby (9 lbs at birth) and suffered a hernia

in his neck at birth as well. This probably contributed to the flatness, along

with laying a lot in his crib at the orphanage.

>

> I am in the beginning stages of trying to get our insurance to cover at least

some of the expense of the helmet, if not all. We have Neighborhood Health

Partnership (which is not United Health) and I have been shut down immediately

over the phone by several representatives. No " orthotics " are covered under our

plan. But, I've got to atleast try!

>

> I honestly have no idea where to begin and am feeling so frustrated.

Thankfully, Ethan is a champ and doing great with the helmet. I am just so

overwhelmed with starting this battle and am hoping someone can point me in the

right direction.

>

> Our dr. office has provided us with the head scans, a letter from the dr, and

the bills that we have paid for the Star Band.''

>

> Any help would be greatly appreciated!

>

> Thanks,

>

>