Denial is not a river in Egypt!!!!!

GinaB · October 18, 2006

No, it's not a river. It's longer, deeper and the waters are much muddier

When I’ve just about lost all hope a tiny ray comes shining through. Yesterday after noon I received a call from my insurer (Highmark BC/BS). It was a girl telling me that she had my appeal and needed to go over a few things. I didn’t understand why SHE had my claim because the last appeal I made was to my employer (Alcoa). She said that Alcoa had contacted her because I had appealed to them in error. The appeal, at that stage, was supposed to be made to the insurer.

The timeline went like this…..My doctor filed my initial paperwork. It was denied. :cry With that denial were instructions on how to appeal to Highmark. I appealed and was denied again. :cry :cry This appeal has no instructions on the next step so I called them and was told that I had exhausted my appeals with Highmark and now had to go to my employer. The proper paperwork was sent to me and I filed an appeal with my employer. This appeal, as it was explained to me, was IT. This was my final attempt at trying to get approved. Until yesterday I’d been waiting 2 weeks and still no word but I was told the process could take 60 days. Then I get this call from Highmark yesterday saying that I was really allowed 2 appeals with Highmark before going to my employer. I had been given mis-information and she apologized.

We spoke for quite a while and she really listened and took the time to hear me out. She said that I had a choice of using my 2nd appeal with Highmark or going straight to my employer. However, if I waived the 2nd appeal and my employer denied me, I couldn’t go back to Highmark. I expressed to her that I didn’t see what good it would do to appeal to Highmark again. Highmark denied the doctor once and me once and both times for the same “experimental/investigational” reasons. She encouraged me to try again. She told me that the first level of appeal went to the medical review board and this current appeal would be seen by an appeals committee. She said that they review appeals in a very different way and look at things that the medical review board wouldn’t. She said that at least if I was denied again by Highmark I would still have another chance up my sleeve with my employer. She really encouraged me not to give up and to use this 2nd appeal. It was like being given a second chance as spinning a wheel to win a million dollars. She even gave me her direct number and told me to call any time. She is going to expedite my appeal and tell them it’s a high priority appeal. She really wants to see this approved by the end of the year because I’ve met all my deductibles .

So, there it is in a nutshell. I’m really trying not to get my hopes up too much but I just have this feeling that this time it’s going to be approved. I have to say it was just nice to finally speak to someone from my insurer that was sweet, kind, considerate and seemed genuinely interested in helping me.:biggrin1:

All of you out there who are waiting and hoping, I’m right there with you. I know how depressing and frustrating it can be. Please try not to loose hope. You never know what the next phone call might bring.

Take care everyone,

Gina B.

Tired_Old_Man · October 18, 2006

Well, you have been through the proverbial mill.

I would file as many appeals as allowed. You might get lucky and have the right person read an appeal. Also, many times when the company sees how persistent you are, they reverse their decision.

Good luck!!