External Reviewer?

[Kelkie 0]

My surgeon's office submitted all my paperwork for VSG to BCBS North Dakota. A week later it was denied. As soon as I got the letter, I faxed my appeal letter with many references to the surgeon's office, they resent all of the information, with a new letter from the surgeon. BCBS has had the appeal for 2 weeks, so I called them yesterday. The nice lady in member services told me it had been reviewed by their dr. in the appeals dept., but they sent it to an external reviewer for another opinion. Does anyone know what that means? I am encouraged that they seem to actually be looking at it, and didn't just immediately say no...I hate waiting!

[MINI-Me 196]

An external reviewer is a medical review team that is not connected with Blue Cross. They evaluate the medical submission and compare to your policy benefits & make a determination about the best course of treatment. I'm surprised they went there before the 2nd internal review. Usually that is reserved as a last step in the process & is requested by the customer. Best of luck!

[Kelkie 0]

Thank you for responding, minime... I agree with you, and that is why I was confused. I can only assume that the internal review team felt they could not make a decision. According to member services, a nurse looked at it first, then it went to the appeals review department, and now external review. Hopefully they will concur with me and my surgeon.

[thisislou 13]

I was denied from BCBS IL - I sent in my appeal and withing 2 weeks - the exteranl board of doctors approved it :

"Reason: Approval is based upon recommendations by an external peer review, after consideration of the member's individual clinical circumstances."

I called the phone number on the lettter I received that said it was sent to the revies board - and was told a week before I received the letter that it was ok.

Lou