HealthNet & Billing Codes

[Nairek]

Ok, I take it that there aren't many NY'ers in here with HealthNet so let me ask this:

Does anyone here have HealthNet & was told by them that TDR is a billable code & has HealthNet paid for the surgery?

I can't get HealthNet to say that they will pay for TDR, only that it is a billable code. It's a longshot but one can dream no?!?

[Harrison]

Karin, with a little phonework, you can get the answer to your question -- call the state insurance commission, and ask for the name of the agency that handles patient appeals and advocacy. They should be able to help you.

Worst case, you can obtain (or go there if convenient) actual cases that were appealed and overturned. Of course, the insurer would be mentioned in the appeal.

Hope this helps.

[sahuaro]

I just searched the HealthNet website and found a 20-something-page document which "explains" why they won't cover artificial disks and lists the codes. If you have HealthNet, you should be able to register to get on and then search the site--this is a national policy. If you can't get on or can't find it, pm me and I will send you a copy.
Interestingly, I also found a HealthNet site for what looks like federal employees and it looks like they do cover at least lumbar ADR for federal employees...
As I am typing this, I can't find the web address for the latter but I will search again and post it when I find it.

[sahuaro]

Here is the address for the New Jersey State Health Benefits Program Member Handbook Plan Year 2007
http://www.state.nj.us/treasury/pensions/epbam/exhibits/healthnet-handbook.pdf (http://www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/healthnet-handbook.pdf)

On p. 18, it states that they will cover one-level Charite.

In the process of searching, I also found a report on external appeals in New York. External appeals are appropriate when the denial is based on a procedure's being experimental (among other reasons). And the insurance company is responsible for paying for the external review. If we all start appealing to this level, it will cost the insurance companies and since they hate to pay out, that should get their attention.
The address is:
http://www,ins.state.ny.us/extapp/extapp05.pdf (http://www.ins.state.ny.us/extapp/extapp05.pdf)

[Harrison]

Excellent, nice digging! http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[Nairek]

Sorry for being a slacker. It's been so busy with work, school, & kitchen renovations that I haven't had the time to spend on the boards here. Thank you both so much for taking the time to respond to my posts.

My husband's company has open enrollment coming up so I may just jump onto his plan. We don't know if Health Net will be an option again or what other plans may be offered.

I took my Empire BC/BS appeal to the External Appeals process. I still lost. That doesn't mean that anyone else who follows this process will suffer the same fate! By all means please use this tool. Perhaps if enough people do this, maybe the insurance industry will wake up!