BCBS denied my claim (Shingles Shot)

[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]

Quote:

Originally Posted by ERD50 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]

Quote:

Originally Posted by youbet 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]

Quote:

Originally Posted by golfnut .......... 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]

Quote:

Originally Posted by travelover I did something similar before a colostomy, which was a month away.

I hope you meant colonoscopy...

[golfnut]

Quote:

Originally Posted by travelover 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]

Quote:

Originally Posted by 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.

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]

Quote:

Originally Posted by REWahoo I hope you meant colonoscopy...

Oops, yes, colonoscopy.

Quote:

Originally Posted by golfnut 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]

Quote:

Originally Posted by golfnut 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.

[golfnut]

Quote:

Originally Posted by travelover 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]

Quote:

Originally Posted by golfnut At least he told you beforehand

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

[rodi]

Quote:

Originally Posted by travelover 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.


Sent from my iPad using Early Retirement Forum

[ERD50]

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