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henry4956 08-25-2014 04:03 PM

Appeal using 'External Review' method
I received a denial on my initial request for reimbursement from Blue Cross World Wide. I had 2 level ADR surgery with Dr Zeegers in April.

There are two ways to appeal a health plan decision:
  • Internal appeal: If your claim is denied or your health insurance coverage cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
  • External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
Has anyone here used the external review process and if so can you elaborate on your story

henry4956 08-25-2014 05:25 PM

David vs Goliath
Just did a search on 'external review'. Not promising. Starting to feel like I am David and Blue Cross is GOLIATH.

FranklySir 08-25-2014 06:25 PM


Second level internal is the first step. Most likely you won't win. You can however resubmit the claim after the second level internal. and or submit to the external appeal. Im going through this right now.

PM me or email better. Don't want to post this here.

henry4956 08-25-2014 07:41 PM

Thanks Frank

jss 08-25-2014 08:07 PM


The only poster on this site I'm aware of that won a third party appeal for ADR has posted her story in this thread. Her appeal is different than yours in that 1)her surgery was domestic rather than international, and 2)she went through the appeals process before surgery, rather than afterwards as you and I did.

She, gymnast1981, doesn't post here any longer but may respond to PM's. BTW: she almost four years post-surgery and is still doing very well.

Wishing you the best of luck with those disingenuous son-of-a-guns at BCBS.


Jen93312 08-26-2014 12:32 AM

Some words of encouragement-David won!:clap:

Kelly4ADR 08-26-2014 02:12 AM

A second to Jens comment, won with a small stone I might add, but you know that Henry! Posted in my thread "cervical two level, Aetna" is my lengthy story so I'll spare you here but I just lost to an external appeal, but we talked about that so you know that too!

I am contemplating filing a suit. As that is the final step, not the external appeal like they want you to think. Everyone, under every plan has this option. I'm praying for guidance on it at this point. Not being hasty, but patience is a virtue, even when in pain.

I will send my paperwork to you this week. Let's share share share info. No one has the time or energy to reinvent the wheel (the appeal, in this case) so let's all fight this fight together. I feel every win is a win for everyone. Even though my surgery is denied, there is still perseverance left in me to pave the path for others. :)

henry4956 08-26-2014 12:32 PM

Thanks Jen & Kel, I recently talked to a guy who had surgery with dr Zeegers (2 level lumbar, like me) back '04' with the Charite. He won with his 1st appeal. He sent me his letter - it was very concise and to the point. He says he felt that it was the particular company he worked for who he feels went to bat for him.

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