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Old 12-01-2015, 10:12 AM   #41
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I think the saga in the OP's first post here implies prior approval.
Well, OP will have to clarify. If the BCBS phone rep clearly stated that he/she was approving the shot in lieu of the doc, then BCBS is clearly in error with the denial. If the phone rep was answering questions regarding the in-network status of the pharmacy or whether OP's age disqualified him for the shot, then OP has an issue: he didn't get prior PCP approval.


But, OP will have to clarify I guess. The phone rep would have had to clearly and directly state he/she was authorizing the shot in lieu of the PCP, not just imply that indirectly.


In any case, if prior approval is the issue, OP can appeal. DW did that years ago when she was with an HMO and got them to make an after the fact exception. The situation was very similar to OP's.
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Old 12-01-2015, 10:21 AM   #42
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I read his post as saying he called to find out if the shot was covered due to his age and at that particular drug store. I don't he called and asked to be excused from the prior approval rule. Thus, I think that's the issue. The BCBS agent could (and should) answer questions about whether his age is OK, the drug store is in network, etc., without granting approval in lieu of the PCP.
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My guess is that the OP would say that the rep should have advised him to get the prior approval along with answering the questions. I would agree with that view.
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Old 12-01-2015, 10:41 AM   #43
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Sometimes I think that the folks who run the financial side of the medical industry are all lined up in front of the Congress and the White House, screaming in loud voices "Please regulate us! We need more rules, more standards and many more bureaucrats to tell us what to do and how to do it."

These boys and girls need to get their act together. They are their own worst enemy.
Of course they aren't. The big companies DO want more regulation. They have the money to move the regulations in the direction that benefits themselves.

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Old 12-01-2015, 10:44 AM   #44
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Not to change the subject matter, but I've recently found that it was much more effective to just go with the formal appeal process when disagreeing with the medical insurance companies.
In the past, I've tried dealing informally with phone calls to the insurance folks, doctor's offices to give insurance company more complete info, etc but with real mixed success.
Recently each of my sons was injured, one a concussion, the other had his hand stomped on.......they both play soccer. My insurance contract has a clause that any medical within 72 hours of accidental injury is covered 100%. The real trick is to get the multiple medical entities (hospital, ER doctor, follow-on doctor, radiologists, etc) to each provide the appropriate info to the insurance companies so that it labeled an accidental injury. ER is usually pretty good but the rest always act clueless when I tell them to be sure to use "codes" or whatever to label the injuries as accidental.
This fall, I just wrote two letters invoking the formal dispute process pointing out that many billings should have been paid at 100% per paragraph xx.x.
To give credit to BC/BS, they got back to me in about two weeks to discuss, I explained what happened and sequence of events (repeating what was in my letter). Took them a couple of weeks to gather more info from the providers, and just yesterday received an EOB showing the last of the claims was paid in full.
In the future, I'm just going the official route, much less hassle other than putting together a complete and accurate letter to kick things off.
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Old 12-01-2015, 10:44 AM   #45
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My guess is that the OP would say that the rep should have advised him to get the prior approval along with answering the questions. I would agree with that view.
That would be nice, but it's not what my experience has been. The insurance companies don't seem to want to staff the phone lines with reps that are authorized to listen to a verbal description of what the customer wants to do and then approve/disapprove and, if approve, pass out an authorization number. Nor do they seem to want to sign up to "if we don't tell you no, then it's yes" situations. Or "if you had a responsibility in the process and we failed to remind you of it during a call" then you're excused from the responsibility.

I'm not sure if their hesitancy to push decision making authority down that low (to the phone clerks) is because they are afraid there would be lapses in consistency or what, but that's the way it seems to be.

Believe me, I sympathize with OP. It's frustrating. That's why I'm glad we're off HMO plans right now. (Although DW is on a Medicare Advantage plan which isn't far from being an HMO.) The rules requiring PCP approval for everything are much more non-negotiable than most clients want to believe (including DW and I at one time).

Still, I'm betting OP can get an exception authorized via a formal appeal. But it'll never happen through informal emails and phone calls. I thought the appeal process was fairly straight forward and worked pretty well. And I can understand why the company needs to restrict exception making to a well defined group of employees who must document the details.
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Old 12-01-2015, 10:48 AM   #46
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but I've recently found that it was much more effective to just go with the formal appeal process when disagreeing with the medical insurance companies...........

In the future, I'm just going the official route, much less hassle other than putting together a complete and accurate letter to kick things off.

+1
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Old 12-01-2015, 12:30 PM   #47
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Well, OP will have to clarify. If the BCBS phone rep clearly stated that he/she was approving the shot in lieu of the doc, then BCBS is clearly in error with the denial. If the phone rep was answering questions regarding the in-network status of the pharmacy or whether OP's age disqualified him for the shot, then OP has an issue: he didn't get prior PCP approval.


But, OP will have to clarify I guess. The phone rep would have had to clearly and directly state he/she was authorizing the shot in lieu of the PCP, not just imply that indirectly.


In any case, if prior approval is the issue, OP can appeal. DW did that years ago when she was with an HMO and got them to make an after the fact exception. The situation was very similar to OP's.
Well, I wish I had recorded it myself, but here's what my shorthand notes to myself on the call say:

I ask about Zostavax - he says Immunizations- covered - preventative

I ask: Deduct? then write No cost to me

I ask: How? (and I think I mention that I've used Costco pharmacy before, are they OK)--- he says Costco (he gives me my local Costco pharmacy address). End of notes

And this little exchange took 30 minutes, he put me on hold several times to check things!

So as I recall, I simply asked if there were any age restrictions on getting this vaccine, and if it is covered, and then I asked how I go about getting it. I want to make sure I'm following the right process for it to be covered. If I needed PCP approval, he should have told me that, but he said I could just go to Costco. No mention of prior approval from PCP.

I was not just asking if Costco Pharmacy was in-network or not, I already knew it was, as I had a prior prescription filled there, and I told him that - I said it was convenient for me and I've used them before. I wanted to know if I got this shot there, would it be covered.

This insurance policy is new to me, and I had not even used any aspect of it at this point (other than paying the premium each month!), I should expect the business to know their policy better than I do. If I needed prior approval through the PCP, then they should have told me.

I don't know if that's any clearer than the OP or not, that pretty much covered it. Without an actual recording, I can't say exactly what was said.

But I will follow up with the actual appeal process. Thanks.

-ERD50
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Old 12-01-2015, 01:03 PM   #48
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I wanted to know if I got this shot there, would it be covered.

. If I needed prior approval through the PCP, then they should have told me.


-ERD50
Errrrrrr.........

I understand your frustration since you probably haven't studied the info book and haven't yet gained knowledge through experience working with this HMO and the various providers. But, the doc pre-approval thing is sooooo prevalent in HMO's, I bet the low level clerks, like the guy you were dealing with, stop mentioning it as a part of every single question they field.

Put the other way around (and I admit I'm doing the "tough love" thing here so please don't take offense) you should have asked if you needed pre-approval. You know you're with an HMO, right? Why did you think this would be an exception? Needing pre-approval is pretty routine.

Your question regarding whether the shot would be covered at that particular drug store doesn't clearly call for an answer as to whether that procedure is a rare exception to the HMO "pre-approval" doctrine. You need to be more suspicious, more cynical. It will never be as simple as a low level clerk telling you "yeah, sure, it's covered, no problem."

Anyway. I've been through similar to what you're dealing with more than once. It makes sense that this can't be cleared up via informal email and phone calls. Submit your appeal and I'm betting you have a excellent chance of winning. But they aren't going to issue an exception informally. They just don't delegate that authority at the level you're dealing with due to gov't compliance and consistency issues.

Crank the handle. Submit the paper. Stop emailing, calling and fretting it for now. You'll get an official answer in writing.

Maybe a glass of some seasonal spiced brew would help?
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Old 12-01-2015, 01:28 PM   #49
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Errrrrrr.........

I understand your frustration since you probably haven't studied the info book and haven't yet gained knowledge through experience working with this HMO and the various providers. But, the doc pre-approval thing is sooooo prevalent in HMO's, I bet the low level clerks, like the guy you were dealing with, stop mentioning it as a part of every single question they field.

Put the other way around (and I admit I'm doing the "tough love" thing here so please don't take offense) you should have asked if you needed pre-approval. You know you're with an HMO, right? Why did you think this would be an exception? Needing pre-approval is pretty routine.

Your question regarding whether the shot would be covered at that particular drug store doesn't clearly call for an answer as to whether that procedure is a rare exception to the HMO "pre-approval" doctrine. You need to be more suspicious, more cynical. It will never be as simple as a low level clerk telling you "yeah, sure, it's covered, no problem."

Anyway. I've been through similar to what you're dealing with more than once. It makes sense that this can't be cleared up via informal email and phone calls. Submit your appeal and I'm betting you have a excellent chance of winning. But they aren't going to issue an exception informally. They just don't delegate that authority at the level you're dealing with due to gov't compliance and consistency issues.

Crank the handle. Submit the paper. Stop emailing, calling and fretting it for now. You'll get an official answer in writing.

Maybe a glass of some seasonal spiced brew would help?
No offence taken, but I haven't been in an HMO for probably decades (I think that was an option with MegaCorp years ago, maybe I'm even mis-remembering that), and even at that, are HMO's from decades ago the same as today? I sure don't know that. I am ignorant in this area, I admit that. That's why I called!

No, I don't know every detail about the PCP approval thing. I know you need to go 'in-network', that is very clear on every single thing, I couldn't miss that. And I know that you can't see a 'specialist' w/o referral from your PCP, that was clear to me. But I honestly thought that preventative care of this sort, when it was emphasized to me that there was no charge at all, and no mention to me of PCP approval requirement, would not be in the same level. Heck, it's just a shot, not brain surgery!

And remember, this was my very first interaction with this coverage, other than paying my premium. I did not know what I did not know. When I looked though the docs they provided, and searched online, there was nothing specifically under 'shingles' or 'Zostavax'. I knew from here and other places, that some insurance coverage had age restrictions. I could find nothing age related in regards to immunizations. Again, that is why I called. And when I was told no charge, I tried to verify the procedure with them, and again, no mention of pre-approval.

I'm not all that worked up (other than just frustrated at BCBSIL), just trying to give the background here why I felt that BCBSIL should have told me about the pre-approval process when I called. It's not like I just called, and asked if Costsco was an in-network Pharmacy, heard 'yes', and hung up. I asked about the process, and had him repeat several times that there would be no charge if I just go to that Costco and get the shot.

Clearly, I understand this pre-approval for everything now. And before DW gets here Shingles shot, we know what to do. But I didn't at the time, and it sure seems to me the BCBS rep should tell you what you need to do to meet his 'no charge' requirements, like did you see your PCP first!

Not much of a seasonal spiced brew kinda guy, but I'll find something interesting later.

-ERD50
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Old 12-01-2015, 02:05 PM   #50
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Clearly, I understand this pre-approval for everything now. -ERD50
Settle down big guy....... ! No need to convince me of anything. I'm just discussing what I think are the ways you have to handle HMO bureaucracy. Not how the bureaucracy should be able to be handled if things were set up right.

This stuff happens. I'd relate a few similar (but way more $$$ involved) I've been through going all the way back to my MegaCorp insurance and right up to recently with DW's Medicare Advantage plan, but I'd be typing all day and everyone would be more than bored. I'll just say the biggest nightmare involved my son developing arnold-chiari as a teen and while our med coverage was a MegaCorp provided HMO. Auuuuuugh! A life threatening condition vs. a sometimes balky HMO. It was a true nightmare.

Assume you need pre-approval for everything except going in to see your primary care doc. He/she doesn't need to pre-approve him/herself. And I suppose granting an appointment is "approval" for you to come in.

Be cynical and suspicious. Phrase questions after you think about whether your wording will get you the required info or not. Put little faith in phone clerks. If you must call, assume the person on the phone is a minimum wage temp worker who had a day of training but didn't pay attention. (An overstatement, but the safe way to look at things.)

Keep things in perspective. This is a couple hundred bux. Irritating but "yawn." Focus on understanding what you need to do to manage your HMO coverage if you or DW need extremely expensive, urgent care. Arm wrestling over $200 is one thing. $200,000 is another.

This too shall pass. Submit the appeal in writing per procedure. Keep emotion and lectures about the quality of their staff out of it. "Just the facts." I'm betting you win and the worse part of the whole thing will be that you let it get under your skin a bit. ( I do the same thing.)
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Old 12-01-2015, 04:08 PM   #51
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Of course they aren't. The big companies DO want more regulation. They have the money to move the regulations in the direction that benefits themselves.

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Good point.
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Old 12-01-2015, 04:12 PM   #52
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Not much of a seasonal spiced brew kinda guy, but I'll find something interesting later.

-ERD50
Well, from what I have heard, Pumpkin Pie Spiced beer doesn't do much to prevent shingles anyway.
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UPDATE from BCBSIL
Old 12-02-2015, 10:55 AM   #53
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UPDATE from BCBSIL

I was busy yesterday and did not get around to filling out the appeal form, and this AM I got a reply from BCBSIL to my last "This is an unacceptable response" reply on their secure email system (bold mine).

Quote:
Please be advised that I have forwarded your request to our appeals department for review of this complaint. They will review the case and send you a formal letter in the mail with the outcome of the appeal review. Please allow additional time for this to be completed.

If you have any further questions or concerns, please contact our customer service department at the toll*free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access.
So, in the opinion of the more experienced here - should I just allow this process to continue, or do I still need to initiate an appeal from my end? Since they specifically mentioned 'appeals department', I'm assuming (but look where that got me!) it would be redundant for me to submit an appeal form?

All the info is in those secure emails - names, dates, ref#'s.

-ERD50
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Old 12-02-2015, 12:27 PM   #54
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I was busy yesterday and did not get around to filling out the appeal form, and this AM I got a reply from BCBSIL to my last "This is an unacceptable response" reply on their secure email system (bold mine).



So, in the opinion of the more experienced here - should I just allow this process to continue, or do I still need to initiate an appeal from my end? Since they specifically mentioned 'appeals department', I'm assuming (but look where that got me!) it would be redundant for me to submit an appeal form?

All the info is in those secure emails - names, dates, ref#'s.

-ERD50
I had a "squabble" with my insurance over a bill being rejected due to the doctor being out of network merely because he was not listed as being in-network at the specific location I saw him at (satellite clinic that is in-network), even though he was listed as in-network at several other locations. I was extra miffed about it because earlier in the year when I had not yet hit my deductible they didn't reject the same circumstances. Called and via phone call questioned the decision, I was asked if I'd like for it to be resubmitted (the rep told me it was unlikely to be changed) and I said yes just to if nothing else, increase their cost in handling the issue.

After that conversation, I recalled the doctor was busy with a another patient at the time of my appointment and I was offered the option of waiting or seeing an associated practitioner immediately. I chose the latter, and was surprised after the fact when this mess came up to find that the practitioner was in-network at the particular location I saw her. Contacted the doctor's office, explained the situation and they were surprised regarding the issue, but agreed to resubmit the billing under the practitioner. Questioned that part of the puzzle too, as I've seen a great number of claims/EOBs with names of doctors not even seen - response was that the supervising MD of the location on the date of visit was the default. Back to the point, it was't very long and a new EOB, still with the unseen doctor's name arrived and was now approved. Not sure if the doctor's office contacted insurance and got them to change their tune, but if that were the case I'd think the practitioner's name would be on the EOB. It seems as if just not settling for the initial rejection and requesting a review may have worked in my favor.
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Old 12-02-2015, 12:51 PM   #55
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Didn't give me the best confidence checking in at the reception desk for my last physical and after handing my insurance card, the receptionist looked puzzled asking "What kind of insurance is this?". She asked to hold on to my insurance card to look further until after my physical, which I said no problem. Probably the fact that the insurance was a BCBS PPO tripped her up. PPO, what's that?
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Old 12-02-2015, 01:12 PM   #56
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ERD50, you already got info about official appeal - that is ONLY way to go, telling as a person involved in claim processing as 3d party. Make sure put keyword 'APPEAL' in the header of your letter, describe situation in facts line by line (bullet points) and reference each EOB, attach copy of your insurance card, copy of the receipt, include all copies of denial EOBs, send by certified letter.
All appeals are registered by insurance company on day when it received, and they have 30 calendar days to review and answer - that is legal requirement and all of them very paranoid to be on time as they get audited for that. All appeals are handled by separate unit that works only with appeals - so they would not know all the story unless you write it clearly in the letter, that will give them enough info to investigate. If it is denied they will give you written instruction how to submit second level of appeal, do not hesitate to submit it - at this point decision will be made not by single person but most likely by the panel. Simple letter from your PCP that you are highly benefited from that vaccinations and would be refereed to do it if asked will go long way also.
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Old 12-02-2015, 01:22 PM   #57
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ERD50, you already got info about official appeal - that is ONLY way to go, telling as a person involved in claim processing as 3d party. Make sure put keyword 'APPEAL' in the header of your letter, describe situation in facts line by line (bullet points) an reference each EOB, attach copy of your insurance card, copy of the receipt, include all copies of denial EOBs, send by certified letter.
All appeals are registered by insurance company on day when it received, and they have 30 calendar days to review and answer - that is legal requirement and all of them very paranoid to be on time as they get audited for that. All appeals are handled by separate unit that work only with appeals - so they would not know all the story unless you write it clearly in the letter, that will give them enough info to investigate. If it is denied they will give you written instruction how to submit second level of appeal, do not hesitate to submit it - at this point decision will be made not by single person but most likely by the panel. Simple letter from your PCP that you are highly benefited from that vaccinations and would be refereed to do it if asked will go long way also.
OK, it does seem too passive to let them handle this as an appeal. That may delay the start of the 30 day period. So I'll start it from my end.

Good point on getting a letter from my PCP that he would have ordered the Shingles shot if I had asked. Even though that is after-the-fact, it shows what would have happened if they had informed me during my call.

-ERD50
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Old 12-02-2015, 01:26 PM   #58
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Having sen this thread it reminded me to persuade DW to get her shingles shot as she turned 60 last week. I got mine earlier this year when I turned 60, at the PCP so on our way back from the Y this morning I stopped by the PCP's office for her to make an appointment and they just gave her it there and then. (When I had mine done they didn't have any in stock and it took a couple of days to get it).
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Old 12-02-2015, 01:27 PM   #59
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OK, it does seem too passive to let them handle this as an appeal. That may delay the start of the 30 day period. So I'll start it from my end.

-ERD50
Insurance can not classify something as appeal unless they have written paper from Provider or Member stating that it is APPEAL. They will be running you in circles with review-reconsideration process and never escalate it to appeal, so you are right- start it yourself and it has to be in writing.
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Old 12-02-2015, 01:42 PM   #60
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I learned something recently about payment for things like shingles shots and flu shots, which are supposedly covered 100% under the ACA. This is a peripheral issue to this thread topic. My insurance is a BCBS PPO. I got a shingles shot at CVS last year after I turned 60, and I didn't have to pay CVS anything. (I eventually received an Explanation of Benefits form from BCBS showing they paid 100%.) This fall when I decided to get a flu shot at a supermarket pharmacy I hadn't used before, I was told I would have to pay upfront, and then submit it to BCBS for reimbursement. They explained that the reason was that the supermarket pharmacy didn't have a contract with BCBS. So I thanked them for the explanation and walked to a nearby CVS and got my flu shot there, since CVS apparently has a contract with BCBS. Like with my shingles shot last year, I didn't have to pay anything myself and then request reimbursement.
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