Re: insurance appeals - Infertility Message Board

TessaL · 04-30-2003, 05:50 AM

I saw that a couple of you are thinking of appealing to your insurance company, and wanted to offer some advice-
1. Put your appeal in writing. The CSR that you talk to when you call has NO power to make anything happen. Call them to get the address for correspondance/appeals. TYPE your letter. Ask for help from your doctor on the wording. The billing dept in an RE's office KNOWS how to get claims paid, lol
2. Just the facts ma'am. Don't attack the company, or use a lot of "feeling" words. Simply state why they should cover what you're asking them to. For example- "I feel that ultrasounds should be covered, as they are not a treatment for infertility" as opposed to "I really want to have a baby, and my husband and I can't afford it on our own." It is going to be the Medical Review dept. at your carrier that determines whether your procedures are covered (at BCBSTX, amde up of RN's and doctors), and emotions won't go far with them.
3. Don't leave your GROUP out of this. Most of us are covered under a group through our employers (or spouse's employer). Believe it or not, the EMPLOYER is the one who decides what is covered, and what is not. Besides having to follow state mandates, they can pick and choose the benefits you get. Let them know that YOU WANT THEM TO COVER INFERTILITY. Tell them why it's important to you. Talk with other female co-workers (they don't have to be diagnosed with infertility to be a proponent for it's coverage) and get some petitions going. Believe me- your insurance company would love to cover EVERYTHING for you, because that means they get higher premiums from your employer.

Okay- that's my lecture for today. Hope it helps someone. Good luck!

MaLaFo · 04-30-2003, 07:59 AM

Hiya Tesss! Excelllent info you gave there! Im also considering it but I have..LOL..where you work, and I have no fertility coverage , they STOPPED PAYINGS U/S, I am using an in network doctor, I pay the full amount, they submit, and they are giving me back full amount I paid..Not fee schedule...I wonder if I start appeals, willl they catch all since Sept and want it all back? My luck, yes they will but that scannnn line you said above, That sounds like it would work, if I had enough balls to start the appeal process..(I dont)

BUT I THOUGHT ABOUT YOU ON MY WAY HOME FROM RE DISMORNING, I go back tomorrow for final blood and hyper exam and do the boooster of HCG but I dont want to pay the 160.00 so I ask you, cus I know its like 628.3 or 4 or 8 for vagiitis? the code? LOL..cus Iffff I go in tomorrow, Im going in with a fake yeast infection and Im paying 10.00 only LOL..So if I can be 1 step ahead of them and yell at the diagnosis code, who would be doing better than me? LOLOL...Any help here, would just about make my mind up to go or not to go! Thank you for your great information and you have a great day! Mare

Mindoo · 04-30-2003, 07:03 PM

Tessa,

Originally, I wasn't going to tell my employer (GROUP) because I don't want them to know. However, one day I was in a meeting with a new HR benefit person, and for some reason I instantly I decided to trust her. I gave her a copy of the appeal that I sent to BCBS. It took BCBS about three months to process the appeal, but this HR lady checked on it weekly. She also strightened out the insurance company's confusion a couple of times. She told me "I don't understand why they are try to review a differt claim. You clearly stated the claims you were appealing in you letter." I got an e-mail on Tuesday showing that they were paying the claim. Attached to it was a copy of every e-mails she sent out asking for the status. She checked a total of 12 times for me. I am so glad I asked her to get involved. I don't think I would have been successful without her.

I think it also helped that I documented every phone call I made to BCBS. In the appeal, I was able to provide them the names, dates, and times, and a summary of the coversation. Three different people told me over the phone that my insurnace covered infertiltiy diagnosis and treatment. They would tell me this over the phone, but they would deny the claim.

I needed everything you said in you advice to win my appeal.

Good Advice!
Mindy

Mindoo · 04-30-2003, 07:12 PM

Mare,

On Feb 3, 2003, I appealed all my claims from May of last year to present. They told me just Tuesday that I won the appeal and I would get reimbused for all the money I put out. My insurance pays for infertility diagnosis and treament, but doesn't cover any procedure that assists reproduction, i.e. IVF, IUI. This definition is sufficently vague enough that they used it to reject all of my initial claims. However, it's also vague enough that I was able to argue that blood work and u/s are diagnostic and therefore should be paid.

It doesn't hurt to ask. Go for it!

Mindy
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CD 16, 12 days until BFP!
hCG shot today, IUI on Thursday.

kateisboo · 04-30-2003, 07:15 PM

THIS IS GREAT INFO!!! Just one specific ?, my insurance company gives me 6 "ovulation induction/monitoring with IUI" and 3 additional ovulation/monitoring inductions. This is the U/Ss, blood work etc. They DO not cover IVF. My gripe is that they should cover the ovulation monitoring with the IVF and I pay for the IVF procedures. It really is the same up to point of retrieval/transfer. Any tips? I am at stage two of the appeal where a board will now look over my gripe!