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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File. |
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#1
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Anyone have the BCBS decision tree?
Hi guys,
was reading about the "Decision Tree" process and Wondered if anyone in our group might have a copy, Thanks Deb
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Deb ___________________________ 1988 diagnosed with DDD, bulging 2012 trauma lumbar following yard work Nov 2012 MRI Bulging discs L4,5, S1 Mild stenosis Dec-Jan PT Jan 2013 Discogram Results Level 5 Annular tears L3-4, L4-5 and L5-S1 Need 3 disc fusion Facet Joints injections, March 2013- no relief Transform.., Epidural Injections 4-23-13 Right L2-3 No relief 2nd ESI 5-14-13 L3-4, L4-5, L5-S1 No relief ugh. ADR L3-4, L4-5, Fusion L5-S1 Fusion Dr.Blumenthal TBI July, 2013 |
#2
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Debbie,
I don't have the tree; however, my cousin, who was a case manager for Aetna explained it to me this way (for Aetna). The first step in the decision tree is a big matrix, which is indexed by codes for conditions and treatments. If you're prescribed treatment is in the cell where the condition and treatment intersect, then a clerk will look at an internal process that is documented for that condition/treatment combination (and there are tens of thousands of these). If the treatment that you are pursuing is not in that cell, you are denied. If your case is unusual enough then it will be assigned to a case manager; who has limited decision making ability and can sometimes approve your treatment. The case manager will look at your case and take it before a board of doctors that will evaluate your condition, prescribed treatment and cost; then make a decision based on that. In her experience, cost was as important a factor as any in deciding which treatment you would get. With BCBS-TX I tried for nine months to be assigned a case manager to which I could speak, but could never get my case pushed beyond the clerks that interpret the matrix. Good luck, Jeff
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C4/5 - ACDF in 2000 C5/6 - ACDF in 2002 C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011 |
#3
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Decision almost made!!
Grover,
Check your Private Messages.
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50 year old female Rear-Ended in 2009 Disk rupture cervical 5-6 & 6-7 2 level M6 ADR, Dr. Clavel - Oct. 2012 Insurance paid Not a day goes by that without me whispering a silent "thank you" to Dr. Clavel Post Op 2+ years Cross Fit 3-5 times a week Running 5ks |
#4
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Deb ___________________________ 1988 diagnosed with DDD, bulging 2012 trauma lumbar following yard work Nov 2012 MRI Bulging discs L4,5, S1 Mild stenosis Dec-Jan PT Jan 2013 Discogram Results Level 5 Annular tears L3-4, L4-5 and L5-S1 Need 3 disc fusion Facet Joints injections, March 2013- no relief Transform.., Epidural Injections 4-23-13 Right L2-3 No relief 2nd ESI 5-14-13 L3-4, L4-5, L5-S1 No relief ugh. ADR L3-4, L4-5, Fusion L5-S1 Fusion Dr.Blumenthal TBI July, 2013 |
#5
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Thanks Jeff,
It sounds like I'm going to have to fight... And I haven't even seen the surgeon yet! LOL! I'm just beginning to put all my stuff in a notebook, as I start to read, test, etc.. Thank your cousin for me.. And hope you're down well. Quote:
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Deb ___________________________ 1988 diagnosed with DDD, bulging 2012 trauma lumbar following yard work Nov 2012 MRI Bulging discs L4,5, S1 Mild stenosis Dec-Jan PT Jan 2013 Discogram Results Level 5 Annular tears L3-4, L4-5 and L5-S1 Need 3 disc fusion Facet Joints injections, March 2013- no relief Transform.., Epidural Injections 4-23-13 Right L2-3 No relief 2nd ESI 5-14-13 L3-4, L4-5, L5-S1 No relief ugh. ADR L3-4, L4-5, Fusion L5-S1 Fusion Dr.Blumenthal TBI July, 2013 |
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