I'm looked at a provider contract (at least in my state), and it explicitly states that not medically neccissary is the responsibility of the provider. On the other hand, a non-covered service is the responsibility of the patient (accupuncture, cosmetic, etc.). The only exception to this is if we have a signed statement from the patient saying that they want the service, realise it may not be covered, and agree to it anyway.
Hi there - I worked for BCBS in Customer Service, I have been on a medical leave, and am no longer employed as I could not return, so I'm not their representative anymore - I have no knowledge firsthand about your policy and your coverage would likely state all benefits are subject to benefits being available at the time of the incident or something.... But anyway, air ambulance is generally not covered. (To me, that always seemed illogical as people generally only take an air ambulance in situations they have no control over, never wanted, and certainly didn't requtest....).
Contact your Customer Service Dept, if you have not already done so, and ask them for the address to the Consumer Affairs Dept. That department is reponsible to review appeals. They review all types of case - by - case situations, and air ambulance is one. What you'll want to do is put your request for appeal in writing...giving as much detail about your situation as possible...they should then request medical documentation - if they don't already have it - to review the case to see if it was medically necessary for air transport.
If you get another denial, I would discuss with your physicians to verify it was necessary and if they agree, maybe try the dept of Insurance in your state. BCBS is required to follow up on those requests for information as well.
I'm looked at a provider contract (at least in my state), and it explicitly states that not medically neccissary is the responsibility of the provider. On the other hand, a non-covered service is the responsibility of the patient (accupuncture, cosmetic, etc.). The only exception to this is if we have a signed statement from the patient saying that they want the service, realise it may not be covered, and agree to it anyway.
Hi Rubindj! I regret the delay in responding. Been down with flare-ups. Hope that you had a happy holiday. Despite everything, holiday with family was good!
My hubby read your post to me and I've been thinking about how to respond. I don't have a copy of your benefit brochure and I am aware that with BCBS that benefits are based on contract benefits specifically listed in the benefit brochure. Usually the provider booklet will state that all benefits are subject to what is specifically listed in the benefit brochure (sorry to be so redundant). But I am aware that the Plans try to be consistent in all their publications.
With regards to emergency services and use of preferred and/or participating providers, there were times when subscribers did not have a CHOICE and were treated by non-participating providers. Therefore, if it truly was an emergency and there was no choice, the claim for services rendered at a facility and billed by an emergency room physician could be reconsidered at the maximum benefit rate (depending on the provider type, services rendered etc.).
In the benefit brochure, there is usually a list of exclusions. One for BCBS is typically no coverage for services that are not medically necessary.
I would have to see the text of your provider booklet and your benefit brochure list of exclusions to determine if a provider with BCBS would ever have to be responsible for a service that was not medically necessary. The logic is that medically necessary is not a benefit (NAB) and those items are always the subscriber's responsibility. A provider with BCBS agrees to accept the allowed amounts as payment in full and only to charge the covered patients for deductibles, non-covered services and copays.
With regards to air ambulance, if your benefit brochure lists it as a covered provider then the services should be covered if medically necessary. Again, the Plan would need documentation to support the transport from facility to facility. It should be covered it the facility could not treat the patient and the patient was transported to the nearest facility that could render the necessary medical care. Reconsiderations should be done in writing as well as appeals and if necessary, get Consumer Affairs, Dept. of Corporations, and your local Congressperson on the case. Consumer Affairs should be a good first try. The Plan's MAIN office should have a dept. If your appeal gets upheld by the Plan, you then have a right to pursue the matter judicially. A court judge will certainly understand the medical necessity and may order the Plan to pay. Have the supporting documentation including your Plan's response to your appeal upholding their decision if you go that route. Good luck!
Last edited by californiasunflower; 01-06-2004 at 09:38 AM.
Hey There
Yep, I've resubmitted the claim & I recieved another denial letter! The letter says....
He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course!
Is this the next step I need to take Consumer Affairs?
Quote:
get Consumer Affairs, Dept. of Corporations, and your local Congressperson on the case. Consumer Affairs should be a good!
I'm getting really aggravated with this whole stituation!
Thanks everyone for the information.
Hey There
Yep, I've resubmitted the claim & I recieved another denial letter! The letter says....
He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course!
Is this the next step I need to take Consumer Affairs?
I'm getting really aggravated with this whole stituation!
Thanks everyone for the information.
Hi Gemi Lee, hang in there. (I was gonna say General Lee
It sounds like they are questioning the basis of treatment, protocol & cardiac classification. Issues...was it AMI or ischemic? The doctor (thank G-d its him and not you) has to provide basis, necessity & prove treatment protocol. How was the pain event determined and what did they base it on? They may be looking for more information to substantiate, so back in the doctors hands it goes. If I were you I would keep resubmitting until they pay it.
It sounds like a tennis, boxing match between the insurance company and the doctor. Keep resubmitting the forms until the insurance company has enough verifiable information from the doctor to satisfy, then finally pay the claim. The insurance company will question chunky disbursements, ask questions first and the provider is explaining his actions. At this point it would seem it is back in the doctors hands to justify this "time response" issue they raise. I'd keep resubmitting and make sure you get copies of what is submitted & the response from both sides until it's resolved. I'd imagine the finding of LAD-The Widowmaker would factor in...Is the clinical course of transient myocardial pain revealing in high risk, LAD AMI cases, subacute or silent? Are the majority of MI cases asymptomatic? Were serum markers & wave changes considered? Is the goal of treatment to restore flow and reduce risk of further complications? Bottom line, the doctor will need to prove medical necessity to the ins. people to their doctors satisfaction (yeah I know, the whole thing stinks) then they will pay it...It was horrible enough you almost lost your life then these people send a shocking bill?!?
I feel for you. Insurance issues are aggravating. There are times I've had to fight and follow up to get medical bills paid, properly coded and what have you, it's terrible. You would think, you do your thing, what your supposed to, think your covered and they pull this out of the hat. It's something else...your on the darn gurney & are still supposed to have presence of mind to question all (sigh) Do I sign the discharge papers so the other place can help me because that’s what the doctors telling me I have to do? It does not exactly instill confidence to get a bill like this but it will work out in the end, it will take time.
I recently received a bill for the professional component that was done over a year ago and this was the first notice I received! I made the gazillion calls to find out who this provider was (not recognized, it ended up being the professional component to the biopsy I had done at a hospital, meanwhile this was not billed through the hospital and was billed privately-ah ha!!!). Everything else was paid for but this. I made more calls and thank G-d for the billing experience I have, I knew to sink my heels in & handle it in that regard. The insurance company said one thing and this providers billing dept. said another. Caught them both in there "tag" game of "not it". What was worse was it was through med. insurance I no longer had. How was I gonna get them to pay this now, so long after the fact? I realized they had their end of quarter coming up and suggested if they could not collect to put it through as a loss because I flat out refused to pay for something that should have been covered & that it's not my problem they don't code or submit the billing within time limits or properly (blah-blah and blah). The insurance company tried to get out of it by claiming it was "out of network" which was untrue (nice try-that loophole) You would think if the hospital is participating the services you receive there are covered but that's not always so, a rude awakening.
The providers office called me back and told me it was going to be paid and the insurance company even sent me a letter confirming the same. It did not happen without aggravation. Hope this encourages you not to give up.
It will work out. It will... Take Care, Gemi
Ps: Let them battle it out. You don't need the added stress of this on top of what you’re already dealing with. Hope you are feeling better
He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course
I just wanted to let everyone know after submitted more documents concerning 'the run sheet' a few weeks ago it finally paid off!
To all of you that help me with information regarding my denial claim......
Blue Cross/Blue Shield is going to pay for my air transportation $9,175.00 this is such great news no more submitting this, trying to find that, I had tears of joy in my eyes believe it or not! they probably won't pay all of it but this will be a big help with all my other medical bills.
Thanks everyone!
I made the gazillion calls to find out who this provider was (not recognized, it ended up being the professional component to the biopsy I had done at a hospital, meanwhile this was not billed through the hospital and was billed privately-ah ha!!!). Everything else was paid for but this. I made more calls and thank G-d for the billing experience I have, I knew to sink my heels in & handle it in that regard. The insurance company said one thing and this providers billing dept. said another. Caught them both in there "tag" game of "not it". 
What was worse was it was through med. insurance I no longer had. How was I gonna get them to pay this now, so long after the fact? I realized they had their end of quarter coming up and suggested if they could not collect to put it through as a loss because I flat out refused to pay for something that should have been covered & that it's not my problem they don't code or submit the billing within time limits or properly (blah-blah and blah). The insurance company tried to get out of it by claiming it was "out of network" which was untrue (nice try-that loophole) You would think if the hospital is participating the services you receive there are covered but that's not always so, a rude awakening. 
Take Care, Gemi
Re: Wanting some information! 
no more submitting this, trying to find that, I had tears of joy in my eyes believe it or not! 
they probably won't pay all of it but this will be a big help with all my other medical bills. 
