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-   -   Anthem BCBS paid 100%, minus co-pay (https://www.adrsupport.org/forums/showthread.php?t=12900)

bwink23 08-31-2014 11:28 PM

Anthem BCBS paid 100%, minus co-pay
 
HI...i got dual neck and back adr surgery covered 100% minus a $550 co-pay by Anthem Blue Cross Blue Shield. My surgery was by Dr. Clavel at Quiron hospital, a preferred provider under them. You can check my posts to see what i did, or PM me if you have questions, i will try to respond.

I kinda-sorta did a pre-authorization, but NOT formally in writing. I checked and made sure my insurance had BlueCard WorldWide, AND that my insurance policy stated that it covered NON-emergency care for covered services outside the country. BCWW gave me a reference number, and even called Quiron for a release of my medical information while i was there, but i opted not to do to give it to them, as i wanted to make copies for me and send them all the necessary paperwork personally.

I sent in all paperwork and supporting documentation and medical records to BlueCard WorldWide. It took them 6 weeks to approve it, but they could not release a check of more than $5,000 to a member, so i had to go through my home base insurance provider, who struggled to get all the information required from Anthem to write the check. I had to give them BCWW service center number, my patient reference number, and some other numbers before they got the information they needed. BlueCard WW keeps all your information on file, and it was MUCH faster for my insurance rep to get documentation from BlueCard WW as opposed to going straight through Anthem BCBS. It was funny, because i could see on my online account i was approved and the amount, but my insurance rep could not LOL.

So, i did have a successful reimbursement at the very least.

FranklySir 09-01-2014 01:15 PM

B,

Congrats!!

Did BCWW reduce the payout amounts as in the discounted rates?

Im finalizing my appeal and want all the ammo I can have. They paid my Cervical like yours but pushed back on the lumbar. They did reduce the bill on the cervical but called it 100% (i assume usual and customary)

Hope your progressing. This stuff takes a lot of time..

Frank

henry4956 09-01-2014 02:09 PM

Man that's great for you. Congratulations. Working on my 1st appeal now. I did what you did, but when I got my case # I specifically asked if they wanted supporting docs over the previous 3 years showing how dire my condition was. They specifically told me to only send the surgery related invoices etc. Do I understand you right, that you sent them additional documentation about procedures, treatments you did before your surgery?

also, you stated: I checked and made sure my insurance had BlueCard WorldWide, AND that my insurance policy stated that it covered NON-emergency care for covered services outside the country

Did they tell you about the NON-emergency coverage or did you read that yourself on your policy?

Hen

bwink23 09-01-2014 08:07 PM

Quote:

Originally Posted by FranklySir (Post 107840)
B,

Congrats!!

Did BCWW reduce the payout amounts as in the discounted rates?

Im finalizing my appeal and want all the ammo I can have. They paid my Cervical like yours but pushed back on the lumbar. They did reduce the bill on the cervical but called it 100% (i assume usual and customary)

Hope your progressing. This stuff takes a lot of time..

Frank

Frank,

No, there was no reduced amount that i could see. The only thing they didn't cover was the co-pay and hotel stay, and 1 year management....I sent around 62,500 over to Spain and got almost 60,000 back. Looks like they covered all of it.

bwink23 09-01-2014 08:24 PM

Quote:

Originally Posted by henry4956 (Post 107842)
Man that's great for you. Congratulations. Working on my 1st appeal now. I did what you did, but when I got my case # I specifically asked if they wanted supporting docs over the previous 3 years showing how dire my condition was. They specifically told me to only send the surgery related invoices etc. Do I understand you right, that you sent them additional documentation about procedures, treatments you did before your surgery?

also, you stated: I checked and made sure my insurance had BlueCard WorldWide, AND that my insurance policy stated that it covered NON-emergency care for covered services outside the country

Did they tell you about the NON-emergency coverage or did you read that yourself on your policy?

Hen

Henry,

I sent everything the first time around. All supporting documentation for prior conservative treatments leading up to surgery, proof of self-payment, letter of medical necessity, itemized billing, information on my surgeon and hospital i went to, lab tests and medical paperwork giving to me by Quiron Hospital, copies of my X-rays. I made sure to highlight that i had contacted my home provider and BCWW prior to surgery to verify coverage. I did not get a formal, written pre-authorization though.

I verified coverage through my Anthem BCBS provider and on my written policy. My written policy states non-emergency care in the paperwork for services outside the country. They told me based on my policy that i could do it for covered services, but would get reimbursed at only a 70% out-of-network rate. I NEVER specified what type of spinal surgery i was having. I didn't want to give them a chance to shoot me down right off the bat. I was merely calling to verify what i saw on my policy, not to get a pre-authorization. Luckily for me, Anthem covered at 100% and not 70%. On BCWW website, it states that Quiron Hospital is a preferred provider of BCBS. I sent a copy of that webpage to them to highlight that in hopes that it would grant me a higher payout. I got it, so maybe it did.

I don't know how your policy reads, but it should state specifically if covered for emergency or non-emergency care. A scheduled surgery would constitute non-emergency, where if say you got hurt while traveling and needed immediate medical attention, that would be emergency.


Hope your appeal goes well for you. It's stupid how they cover some people and not others for the SAME operations. Once someone breaks down that door, it should stay open for everyone.

henry4956 09-02-2014 12:15 PM

BWink, I checked today to verify about overseas medical coverage that is NOT of an emergency nature. I do not, as I suspected have it.

I do have an excellent plan, it has covered so many things in the past - but yours is sensational with that overseas feature. Based on your issues, I'm sure you consider it a blessing not only because you got your 60k back but potentially going forward as you try and resolve the ongoing issues.

Take full advantage of your great health coverage policy and good luck, really

Hen

Jerry5 09-02-2014 08:54 PM

Bcww
 
Called today, for reimbursement, hope this goes well, I sent them a lot of information.
I actually had two surgeries, an ADR, the M6, this they may haggle about, and the second was a fusion, doubt they will argue about that one, we will see, I should know in a week or so, will keep this posted.

henry4956 09-03-2014 10:34 AM

So far in the whacky world of BCBS I have received (2) different reasons for denial. Via phone days before I received the official denial in mail I was told that it was all about the 'emergency' vs 'planned' thing. In the mail they said ADR was not appropriate for 'ongoing low back pain' & lack of peer reviewed evidence concerning ADR.

Excuse me I had severe DDD, but because they insisted that I only send them documents pertaining to the surgery they did not see testimony by 3 spine docs concerning my severe DDD. This is crazy

Now the icing on the cake. They have so far sent me 2 checks. One for $140 the P.T. cost & one for $600 the cost of the ambulance, the last one ($600) came days after the denial letter. all together now boys 1-2-3 puke :puke::puke::puke::puke::puke::puke::puke:

bwink23 09-03-2014 11:10 AM

Henry,

yeah, i am pretty much an outlier in regards to the non-emergency medical care. Unfortunately, i can only afford 3 more months of it, then will have to drop it and go on wife's insurance (also Anthem BCBS). Hopefully though, i won't need to make any oversea trips in the foreseeable future. Still, having that was no guarantee they would cover ADR's. I got extremely lucky.

henry4956 09-03-2014 12:52 PM

For what you've been through, consider it a blessing. You deserve it. I will be closely following your ongoing journey. My gut tells me, your solution is near. keep the faith bro

Hen


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