Denial-next peer to peer and or Appeal

[jodie1961 77]

Long story short...denied for revision from band to rny in December 2013. Insurance girl at Doc's office said we needed to re-do classes, psych eval, etc. Did this and got approval letter from NUT, Psych Dr, and Doc 2/7/13. Insurance girl didn't send in new clinical info to insurance until 2/26...after 10 business days I called Anthem and they said they had no new request on file. Called Doc office, insurance girl called me back and assured me they had everything. Still no word as of today...so I called Anthem again: a supervisor finally got on the phone and said there is no case pending. New clinical info doesn't do anything. the original request was denied -not medically necessary and now the only option is to have my Doctor call and have a peer to peer meeting to discuss, and/or file an appeal. (neither have been done.) Sooooooo in other words I have been waiting for NOTHING for nearly 2 months. I have to call my Doc's office Monday and talk to the insurance girl about scheduling a peer to peer meeting now. What is going on? Why would she not know this was needed? Why would Anthem continually tell me the case was pending when I called to check? I am soooooooooooo frustrated and depressed. Has anyone else ever been thru this?

[Melanie36 71]

I'm so sorry this is happening-- it's funny that they make us see a psychologist, but half of my problem is the stress about the process! :-)

My surgeon told our group that if we get declined at first to not panic yet--- that about half the time he has to get on the phone and "chat" with the insurance to push it.

Good luck to you! I'll wish for the best!

[jodie1961 77]

I'm so sorry this is happening-- it's funny that they make us see a psychologist, but half of my problem is the stress about the process! :-)

My surgeon told our group that if we get declined at first to not panic yet--- that about half the time he has to get on the phone and "chat" with the insurance to push it.

Good luck to you! I'll wish for the best!

Thank you Melanie36 for telling me that. I haven't seen too many discuss the denial and appeal process. I pray the "chat" will do it. And I agree the stress of waiting and not knowing is killing me. Trying to keep my chin up, but just such a blow yesterday, it was almost a knock out....but, not quite I will succeed.

[jodie1961 77]

I called this morning and got my Doctor's insurance clerk's voicemail. Left a short message, basically that I had spoken to an insurance service rep's supervisor and I needed to talk to her as soon as I could, left my number. After lunch, no call, so I called the main office, got an answer machine again, left a message for the receptionist to contact me and no call. Tomorrow, I will call in the morning again, and if I don't hear back, I well take a late lunch and go to their office. I don't believe there is an office manager there. They are short handed, one girl left at the first of the year. Am I expecting too much? I have been waiting since February 7th for an answer, and really should have had a peer to peer meeting scheduled after my December letter of request was denied. Any ideas?

[jodie1961 77]

Well, today I spoke w/doc's receptionist. Bless her heart, she was swamped the insurance clerk is no longer with them. I believe I am not the only issue with problems stemming from her work/lack of work. The receptionist has all the details and was going to call the insurance company herself and get Doc scheduled to do the peer to peer meeting with Anthem. Hopefully, this will help them to reverse their original denial decision. I see him next Monday either way. Praying this works. Thanks for being a forum I can vent to, share with and get through this whole process with.

[jodie1961 77]

Debbie (receptionist) called today and said she has the peer to peer meeting scheduled with my doctor and Anthem. I really don't understand exactly if this can reverse the original denial, or if it makes the appeal process have a better outcome? Has anyone else ever had a peer to peer meeting done on their case before being approved?