BCBS denied my claim (Shingles Shot)

[Chuckanut]

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.

Regulatory Capture Definition | Investopedia

Good point.

 

[Chuckanut]

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.

 

[ERD50]

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).

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

 

[Theseus]

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.

 

[easysurfer]

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?

 

[Exit 2024]

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.

 

[ERD50]

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

 

[Alan]

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).

 

[Exit 2024]

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.

 

[anethum]

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.

 

[rdy2go]

You can start a complaint with your state's Department of Insurance. Explain that you called BC/BS, were told it was covered and that they directed you to Costco. You relied on their people being competent and knowing your coverage and eligibility. documentation in detail will help. Odds are they will decide that they would rather cover the shot than have to deal with another complaint. But then, they may have a large department that does nothing other than responding to the insurance department all day long.

 

[youbet]

should I just allow this process to continue, or do I still need to initiate an appeal from my end?
-ERD50

Hard to say. On the one hand, a second appeal, might cause some confusion. On the other, you'll have a chance to express the details concisely in one letter/form as opposed to how the appeals dept might put together the various emails you've been shooting back and forth and which now have been forwarded to them.

I guess I'd send the letter/form, but I'd do it immediately and include the information that the rep has also submitted an appeal.

DW and I are chuckling a bit over your situation because we walked over those same hot coals in the past. We learned, and you have too, that when you have a "disagreement" with the med insurance carrier you do not begin a series of emails or phone calls debating it with clerks. You make one quick call or email to be sure it isn't a discrepancy they can easily fix at a low level. And then you go to an official appeal. But no back and forth, back and forth debating with the clerks.

If it turns out that your appeal is denied, then the debating starts but it will be with folks authorized to make decisions.

You won't need to write the state insurance regulators until and if your appeal is denied.

Sigh......

It's life in the USA.

 

[MBSC]

Hard to say. On the one hand, a second appeal, might cause some confusion. On the other, you'll have a chance to express the details concisely in one letter/form as opposed to how the appeals dept might put together the various emails you've been shooting back and forth and which now have been forwarded to them.

I guess I'd send the letter/form, but I'd do it immediately and include the information that the rep has also submitted an appeal.

You make one quick call or email to be sure it isn't a discrepancy they can easily fix at a low level. And then you go to an official appeal. But no back and forth, back and forth debating with the clerks.

You won't need to write the state insurance regulators until and if your appeal is denied.

+1

Your appeal will be more detailed than the one forwarded by the CSR. If your appeal is denied, the denial letter will explain the next steps to take in your state, such as contacting the DOI or an external review board.

 

[braumeister]

I've looked at this thread with considerable amusement.

A few years ago I decided to get the shingles shot (I was already over 60) because when I actually had shingles some years previously it was pure agony. I had read that the shot was still a good preventive measure even for those like me.

There was no insurance coverage for it so I just went to the local pharmacy and paid $225 for the shot.

About a week later, my insurance changed their policy and said that effective immediately it would be fully covered.


Truly, timing is everything.

 

[golfnut]

First of all, sorry to hear about the issues with BCBS of ILL. Hope they are resolved in your favor.

I have a ACA plan with them and it's a ppo. Based on what I read here, I sent them an email asking them to confirm the vaccine is free of charge and what steps need to be undertaken. I am 60 yrs. old.

 

[travelover]

.......... I sent them an email asking them to confirm the vaccine is free of charge and what steps need to be undertaken. ...........

I did something similar before a colostomy, which was a month away. I got an answer back two months later. Thankfully the answer was yes, it was covered.

 

[REWahoo]

I did something similar before a colostomy, which was a month away.

I hope you meant colonoscopy...

 

[golfnut]

I did something similar before a colostomy, which was a month away. I got an answer back two months later. Thankfully the answer was yes, it was covered.

Plus it was a timely answer.

Was this your first colonoscopy? Reason I ask is next year, I'm due for a 3rd one (unfortunately, I'm on the 5 yr plan). Fortunately, the first 2 procedures were free of charge.

 

[Car-Guy]

My insurance company pays 100% of many preventive shots. e.g. Shingles, Pneumococcal and Flu to name some of the more common ones that I have got.

However, they changed their policy last year, and didn't say anything (unless you read the fine print) that they will only pay for these when given at a doctors office. No coverage if these shots are given at a pharmacy. I'm not sure why since the costs seems to be the same for the ones I've checked on, no matter if at a doctors office or pharmacy.

 

[John Galt III]

Not sure PPO's are any better than HMO's for being clear about what is covered. I have Highmark Blue Shield PPO and their customer service folks are clueless. Call back, get a different agent, get a different answer.

 

[audreyh1]

First of all, sorry to hear about the issues with BCBS of ILL. Hope they are resolved in your favor.

I have a ACA plan with them and it's a ppo. Based on what I read here, I sent them an email asking them to confirm the vaccine is free of charge and what steps need to be undertaken. I am 60 yrs. old.

I was on a BCBS TX PPO, and Costco called them and got it approved before they gave me the vaccine and charged me $0. I was 55 at the time.

 

[littleb]

Have you thought about getting a letter from the Primary Doctor authorizing the shot and then writing a letter of appeal to BC based on the representative telling you it was covered under the plan? Shingle shots are not flu shots and there are restrictions under every health policy. The representative should have taken the time to review the plan benefits and your age before she told you anything. It was her mistake.


I have appealed denied claims twice and they reversed and paid them based on extenuating circumstance.

 

[rdy2go]

Our health plan last year would pay 100% for a shingles shot if administered by our doctor but doctors would not keep the vaccine in their offices. My wife had it done at the pharmacy and sent a copy of her receipt to the insurance company and they sent her a check for the shot. Covered but not covered but paid anyway.

 

[travelover]

I hope you meant colonoscopy...

Oops, yes, colonoscopy.

Plus it was a timely answer.

Was this your first colonoscopy? Reason I ask is next year, I'm due for a 3rd one (unfortunately, I'm on the 5 yr plan). Fortunately, the first 2 procedures were free of charge.

It was my first. Previously I had a sigmoidoscopy and as I lay there naked, ready for the insertion the physician said to me, "you do know your insurance won't cover this, right?"

 

[ziggy29]

Was this your first colonoscopy? Reason I ask is next year, I'm due for a 3rd one (unfortunately, I'm on the 5 yr plan). Fortunately, the first 2 procedures were free of charge.

Yeah, I just turned 50 a couple months ago I guess this is something I need to be prepared to deal with now. Most of the health plans available to me pay for one preventative colonoscopy every 5 years starting at age 50, and annual FOBT screenings.