anyone successfully appealed medical group's referral to a specific provider?

[Guest guest]

We live in Southern California, have Blue Shield Access Plus HMO, and our

medical group is Facey. My pediatrician referred our son to Cranial

Technologies for his helmet, but Facey does not contract with them. The

referral for the helmet was approved (meaning he meets Blue Shield's criteria

for the helmet being a medical necessity), but Facey pushed the referral through

to Hanger instead of CT, because they contract with Hanger. After consultations

at both, we are going with CT and will be paying out of pocket.

Here is the twist - I have spoken to Blue Shield, who has told me that if Facey

would have approved an out-of-network referral, I DO have out-of-network

benefits that would pay $1671 toward the cost of the CT DOC band. Facey is

telling me that they will never refer out-of-network if there is an in-network

provider that they contract with. I know that I have an HMO, but I feel that

this is really unfair. If Blue Shield is telling me that I have out-of-network

benefits, and I as the patient am willing to make up the difference between what

they will pay and the total cost of the helmet, who is Facey to tell me that I

can't go to CT?

I am wondering if anyone has ever appealed their medical group's decision on

where they were referred for a helmet. I want to appeal, but I talked to my

pediatrician today and he flat-out told me that it would be a waste of my time.

This is my first experience having to deal with my health insurance and medical

group in this manner, so I figure someone out there knows more about it than me!

Thanks!

le

son Jace, 4 months, due to go into a Doc Band 11-02-10