Quote:
Originally Posted by henry4956
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
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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.