BCBS denied my claim (Shingles Shot)

[golfnut]

Oops, yes, colonoscopy.

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?"

At least he told you beforehand

 

[travelover]

At least he told you beforehand

I kinda felt like I'd taken it in the keister twice that day.

 

[rodi]

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?"

Yikes - not something you want to find out AFTER all the prep.

I was on the 5 year frequent probing schedule... but finally graduated to 10 years after a few "clean" scopes. Haven't had one on my new ACA HDHP.

 

[CherylGrrl]

I am covered by BCBS and called them when I was 59, a couple of years ago, to ask about coverage for the shingles vaccine. They told me that at one time the vaccine was in short supply so they had the age 60 restriction to make sure there was enough vaccine available for the older people who needed t the most. She said there as no longer a shortage, and they now cover the vaccination for people over 50! I went to Costco for the shot and it was free.


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[ERD50]

An Update - next step

So I wrote after they said they were submitting my complaint to the appeals department, and asked if this was the same procedure as if I submitted the appeals form myself (and I gave the link to the form). They replied:

Yes, the appeal that was forwarded for review is the same as if you filled out and submitted the form yourself. Please allow additional time for the appeal to be reviewed and completed. You will be notified of the determination once the review has been completed.​

Hmmmm, so I guess I'll wait and see.

-ERD50

 

[iac1003]

FYI - use the State Insurance Commission only as a last resort after all appeals have been exhausted. It will not speed things up, in fact it will delay them by months to years. And once you file a claim with the State the insurance company will no longer talk to you about your case as it is in the hands of the Insurance Commission.

Happened to a friend of mine - and it took 2 years for the case to be adjudicated.


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[youbet]

Hmmmm, so I guess I'll wait and see.

-ERD50

You say this as though you have a choice........

If you're a mature person with a bit of self-control, you'll now forget this until your tickler file alarm goes off in 6 weeks and, if you haven't heard from them, send a follow-up (in writing).

If you're more like me, you'll fret about it constantly, tell everyone you know about it at holiday parties boring them to death and drive yourself nuts until the answer comes in. Even though all this will do no good........

 

[ERD50]

You say this as though you have a choice........

Well, there was an alternative mentioned in this thread - that if I filled out the appeal, it would have all of my viewpoint. I don't know exactly what information went into their appeal. Maybe I'll ask them about that.

But that would put two appeals in the system, and that might screw things up. So I'll wait it out.

If you're a mature person with a bit of self-control, you'll now forget this until your tickler file alarm goes off in 6 weeks and, if you haven't heard from them, send a follow-up (in writing).

If you're more like me, you'll fret about it constantly, tell everyone you know about it at holiday parties boring them to death and drive yourself nuts until the answer comes in. Even though all this will do no good........

I plan on waiting, but my post was just to update the thread. I always hate it when people post a problem, get input, and then don't post back as things move along.

So otherwise, you won't hear from me on this subject for another 5-6 weeks. And people in my circle have already heard enough - I'll cut them some slack at this point!

-ERD50

 

[ERD50]

Update

... I plan on waiting, but my post was just to update the thread. I always hate it when people post a problem, get input, and then don't post back as things move along.

So otherwise, you won't hear from me on this subject for another 5-6 weeks. And people in my circle have already heard enough - I'll cut them some slack at this point!

Well, I was thinking it's been about 6 weeks, I was planning to check up on this next week, and I get an email from BCBSIL tonight, "Your Blue Cross and Blue Shield of Illinois Claim Has Been Finalized". Hmmm....

So I fully expect "Denied", ho-hum, that's it I guess, but I see entries that seem to indicate it was approved. No, that can't be. But I dig around, find the EOB, and there it is in black & white:

" A payment of $217.05 was made to [my name] on 01-19-16 check # xxxxxxx "​

Hard to believe. It seems rather anti-climatic after all it took to get it, but heck, I got it!

And, I don't have the Shingles! Now, to get DW to go through her PCP and get the shot the right way!

So, I got my money, and learned a lesson about HMOs. But I also learned that you can't go by what they tell you when you call them, or what they say on the follow up calls on that subject (*). I am not looking forward to my next interaction with them


(*) I guess the most frustrating part of this, is when I followed up, they said, "OK, just submit it as a medical claim - it went in as a pharmacy claim, that is why it was denied". So I filled out the Medical Claim paperwork, sent that in, and waited... Denied! That led to more back-forth, and the appeal process, rather than phone call resolution attempts, which I guess is the other lesson I learned (go the 'appeals' route early on).

Thanks to all who helped with suggestions, or just commiserated!

-ERD50

 

[zinger1457]

I got the shingles vaccine during my annual physical last month and had no issues with BCBS-AZ paying for it although the doctor did warn me there may be a payment issue. He was under the impression that the insurance would only pay for it for those >60yo but I did check with BCBS beforehand and they confirmed it was now anyone >50yo.

 

[travelover]

He was under the impression that the insurance would only pay for it for those >60yo but I did check with BCBS beforehand and they confirmed it was now anyone >50yo.

Widespread ignorance out there. The pharmacist that gave me the shot thought it was illegal to give it to anyone under 60.

 

[Sue J]

After all we went through (see post #27 in this thread), DH's shingles shot got coded by the insurance company as "out of network" and was not paid. I saw this on the claims website and immediately called. The customer rep said she didn't see why it was out of network, the location is obviously a network facility. So she sent it for review, expect 4-6 weeks to have it go through. That was on 12/11. Hmmmm.......

 

[ERD50]

I got the shingles vaccine during my annual physical last month and had no issues with BCBS-AZ paying for it although the doctor did warn me there may be a payment issue. He was under the impression that the insurance would only pay for it for those >60yo but I did check with BCBS beforehand and they confirmed it was now anyone >50yo.

It's a long thread, so I'll try to give the Reader's Digest version...

A) I wasn't sure if there were age restrictions or not, so I called BCBS to find out. I was told no, no age restrictions (or at least I met them, I forget which). I was also told this was preventative, and is covered 100%, no out-of-pocket at all.

B) I then asked if I could go to Costco to get the shot, as I had already picked up some meds there. He verified that as a yes, and even read the address of my local Costco to me, so I thought we were all on the same page. Again, he confirms zero $ OOP.

C) The claim is denied. To keep it short for now, the bottom line is, they require my PCP to authorize the shot, and then I go where my PCP tells me to go (maybe my Doc's office?) to get the shot. But none of this was communicated to me on that call. Fortunately, I kept notes on names and times/dates.

Slightly longer version/details: - the first time I called BCBSIL to question the denial, I'm told to wait for the EOB to appear, but weeks later, no EOB. Then I was told that the problem was that it was submitted as a Pharmacy Claim, and it needs to be submitted as a Medical Claim. If I download the Medical Claim form, fill out and send that in (and they need original receipts, that always scares me, what if they get lost?), I will be paid.

Well, that gets denied. So now they are telling me I needed approval from the PCP. OK, then why didn't the first person tell me that, and why did the second person have me jump through the hoops of filling out a Medical Claim if that wasn't what was needed (and I provide names/dates of those calls)?

Additional back-forth, review.... denied again. I push some more, and it got elevated to a formal 'Appeal' (which I should have started earlier I know now). About 5 weeks later, appeal is approved. Shot was back on AUG 25, 2015.

Bottom line, if you call BCBSIL, you can't rely on the info they provide. And I don't feel their documentation covers every detail (like ages for Shingles Shot). Maybe the PCP would know this, so going through the PCP would have denied me if I was not in the age group? Maybe? Maybe not? Can they really know every detail of every insurance co?

All I know is I hate the thought of dealing with any future claims, regardless how minor, and I ought to feel better about this considering the amount of money I send them each month. Very frustrating. But is any other company in IL any better? I have no idea.

-ERD50

 

[ERD50]

I got the shingles vaccine during my annual physical last month and had no issues with BCBS-AZ paying for it although the doctor did warn me there may be a payment issue. ...

This is part of my frustration. Shouldn't we know, is it covered? Yes, No? Why "might" there be an issue?

Really not such a big deal in this case, I would pay $200 OOP for the shingles protection (shingles can be very painful). But I should know going in if it is covered or not.

And it's not like a shingles shot is some odd, rare, unconventional thing. It's routine for people >60 (maybe >50 now?), so this should be a slam dunk question/answer.

I can't imagine the unfortunate people who need to deal with complicated issues!

-ERD50

 

[Sue J]

Update to DHs shingles shot debacle.....

He got the vaccine on 11/20/15 at a network pharmacy but it was coded at non-network by mistake when submitted.

Nothing ever happened with this being resubmitted. We finally got a bill from the grocery store pharmacy for $212 in late April. I called the insurance company who said that they had resubmitted the claim back in December but there was nothing in the records to show that any action was taken. The customer rep said she would resubmit it as a high priority.

Wonder of wonders......I checked DHs claims site today and it's been PAID! It now shows that it was an in-network provider and that payment was sent to the pharmacy earlier this week.

Finally got this one done.

 

[audreyh1]

Update to DHs shingles shot debacle.....

Nothing ever happened with this being resubmitted. We finally got a bill from the grocery store pharmacy for $212 in late April. I called the insurance comapny who said that they had resubmitted the claim back in December but there was nothing in the records to show that any action was taken. The customer rep said she would resubmit it as a high priority.

Wonder of wonders......I checked DHs claims site today and it's been PAID! It now shows that it was an in-network provider and that payment was sent to the pharmacy earlier this week.

Finally got this one done.

Yay!

Wow - that took a while!!! Well - not so long after it was resubmitted high priority by the customer rep.

 

[bingybear]

No, the pharmacy is in network, they are saying I needed approval from my Primary Care Physician before getting the shot. And my stance is that when I called, they just told me I could go to the pharmacy directly, so I did.

Had I known I needed PCP approval, I would have gotten it, no big deal, and that would have saved me $217.

Well, even if I don't get anywhere, maybe this will help save someone else some grief. But since the rules may be different for many, not sure how much it will help, but at least some will be warned.

-ERD50

Do you have a plan that requires a gate keeper (PCP) to approve all procedures? If so... you should have known that everything must be approved/recommended by your PCP. If not, you may have a valid point.

My present plan actually notes that I don't even have to select a PCP and I don't need a PCP referral. But if you are required a PCP referral... then always use one.

 

[ERD50]

Do you have a plan that requires a gate keeper (PCP) to approve all procedures? If so... you should have known that everything must be approved/recommended by your PCP. If not, you may have a valid point.

My present plan actually notes that I don't even have to select a PCP and I don't need a PCP referral. But if you are required a PCP referral... then always use one.

To re-hash (that's OK, it's a long thread), I know that now.

This plan was new to me, and that is why I called to find out what the procedure was for getting a shingles shot. That's when they told me I could just go to Costco, zero $ OOP. So I did.

But they were wrong, I need PCP approval. But they didn't know that, how was I to know? Don't they do this for a living?

After formal appeal (after a number of hoops and denials), they paid it based on the fact that they gave me wrong information.

-ERD50

 

[easysurfer]

To re-hash (that's OK, it's a long thread), I know that now.

This plan was new to me, and that is why I called to find out what the procedure was for getting a shingles shot. That's when they told me I could just go to Costco, zero $ OOP. So I did.

But they were wrong, I need PCP approval. But they didn't know that, how was I to know? Don't they do this for a living?

After formal appeal (after a number of hoops and denials), they paid it based on the fact that they gave me wrong information.

-ERD50

Seems like now we need a PCP approval for just about anything. For the sake of cost cutting, of course.

 

[ziggy29]

Seems like now we need a PCP approval for just about anything. For the sake of cost cutting, of course.

Should be the case primarily for HMOs, I think. HMO plans generally require the PCP to be the "gatekeeper" to approve care and refer you to other specialists.

I suppose there may be PPOs that do this too, but I'm not sure. PPOs generally have the feature of not requiring a referral to a specialist by a designated PCP.

 

[easysurfer]

Should be the case primarily for HMOs, I think. HMO plans generally require the PCP to be the "gatekeeper" to approve care and refer you to other specialists.

I suppose there may be PPOs that do this too, but I'm not sure. PPOs generally have the feature of not requiring a referral to a specialist by a designated PCP.

The BCBS plan I had last year got eliminated and now I'm in a BCBS Choice plan which requires the PCP approvals. The word Choice is customer choice but BCBS Choice of where you are allowed to go .

 

[ohyes]

To re-hash (that's OK, it's a long thread), I know that now.

This plan was new to me, and that is why I called to find out what the procedure was for getting a shingles shot. That's when they told me I could just go to Costco, zero $ OOP. So I did.

But they were wrong, I need PCP approval. But they didn't know that, how was I to know? Don't they do this for a living?

After formal appeal (after a number of hoops and denials), they paid it based on the fact that they gave me wrong information.

-ERD50

Happy for you; thanks for the update.

DH and I have been discussing getting the shingles vaccine for weeks. An acquaintance, with other serious health concerns, is now blind in one eye because of shingles. With both of us being at least 60, DH and I are starting to pay attention to the seriousness of this.

Referral from PCP is next. (Thanks, again).