Did your insurance pay? Let's help one another

[ESL]

i have posted this several times on many parts of this board, but no one seems to really notice....however it is a very important nuance wiht regard to the willingness of insurance companies to approve procedures......and that is that another factor is whether insurance thru your employers is a fully insured plan (in which case the decision to cover or not cover adr is up to the insurance companies) or a self-retention/self-insured plan (in which case the insurance company administers the employers insurance plan and appeals are up to the employer....usually a manager/management team/or cross hierarchal committee).

I am not trying to grind an axe, but just want to help raise everyone's awareness.

[NCFUSED]

ESL is totally correct, after 2 appeals with UHC,
which really were a waste of time because my company is self insured, the final denial letter from UHC told me to seek another appeal from my employer's benefit's committee, that they were the only ones that could overrule the medical policy that was in place.

One other thing I found out is with Self-insured plans, you cannot appeal to the state's insurance board. You would have to file a grievence with the Dept. of Labor, basically "marking" yourself at your job....

[cavalib]

DWebster,
Which insurance do you have? DId you have to go through any appeals?

[cavalib]

Does anyone know if Cigna Open Access Plus approved anybody from Florida? Does it make it harder to get approved if you are having the surgery in a different state? Sorry for all the questions but I am new at this and I didn't think I would be having all these problems when I first looked into the surgery. If anyone has any information that will help me please let me know. Thank you so much!

[ans]

Wonder what the secret formula BC of CA uses in saying yea/nea in acceptance - both in group or individual plans. For that matter, any ins. company.

[walker]

"Secret Formula"--what a way to put it! I guess that is what I am looking for. If I only knew how to cut out the nonsense/time-wasting appeal methods and cut straight to the chase and get a positive result. We need an insider - - - Someone who knows those magic words!!!! Hmmmmm.

[inflexable]

I was scheduled for adr @ l5-s1 on 4/8 but was just denied 3/29 "investigational/experimental" was the reason (excuse) given. The insurance co is highmark bc/bs of western PA. They are a 3rd party administrator for the company I work for that is self insured. My employer told me they can't tell bc/bs what to do...I wonder?? anyway I am appealing. I live in MD but my employer is based in pa with branches in maryland. My doctor was told by bc/bs during the peer to peer review "we are not paying for ANY disc replacments". I feel like they already have their minds made up to deny any appeals and that this is just a formality for them. Anyone else have the same insurer?

[ans]

We must do recon on different utilization boards!

Wine/dine/romance/even marry Utilization Review folks and let's hear the secrets.

[letteski]

I am insured with Health Comp through Universal Health Network out of Northern Nevada. I spoke with my case manager yesterday at UHN and she said I was the first case she asked for authorization on for ADR. I was approved on March 14'05. Regan's office said I was the first to come in with pre authorization. Heath Comp pays the bills and I must remember, "Nothing is a guarantee of payment".

[ESL]

Paulette are you part of a self-insured plan thru your employer? My employer is self-insured with healthcomp as the third party administrator....their case management people are top notch.