Denial from CareFirst BCBS

[Jrs_lovely1 12]

Hello everyone. last week I found out that I received a denial due to not having the supporting documents demonstrating a structured nutrition program within 2 years preceding the submittal to insurance.

I do have the documentation and just sent it to the surgeons office today to forward on to my insurance for an appeal.

My concern is yet again the surgeons office. When I was informed of the denial, the administration nurse told me that I needed to have the program completed after the submission to my insurance. I have had issues with the administration part of the office since day 1 and followed up myself and found out that was incorrect. It has to be prior.

I am afraid that they are going to hold my forms based off their understanding of the policy. Of course my thought is to submit it myself but my insurance company said that the appeal has to be through the surgeons office.

Any advice on this? I'm thinking of asking for a conference call between the office, insurance and myself so that we can all be on the same page. It took forever to get them to submit my packet in the first place.

Also what are the chances of an approval after a denial?

[samuelsmom 670]

Since you have the documentation, hopefully it will be smoothe. There are lots of people that have to appeal and are successful doing so.

As far as the doctor's office goes, I would suggest meeting with the office manager to share your concerns. Also, I would suggest writing a letter to the insurance company detailing your weight loss efforts and attaching the documentation anyway! That way you can be sure they have the information and gives you some leverage.

Good Luck

[Jrs_lovely1 12]

Thanks for the advice. I actually took the documentation up to the office on yesterday after I called to verify the fax and they stated that it was not received. It gave me the opportunity to do what you suggested and write a statement of my efforts throughout this struggle with weight loss.

After I dropped the documents off I waited a couple of hours and then called the office to speak with the scheduler. She is the one who creates the most confusion with this process. I asked her what are the next steps for proceeding with the appeal? She said the surgeon was out of the office until Friday. She has to review the documents and sign them before she is able to send them to the insurance. So I am going to follow up on either Friday or Monday. Generally I hate to be a bother but I feel like the only way I have got any results is by applying pressure on her.

As far as speaking to the office manager, I did speak to someone (not manager) and voiced my frustration. I also spoke to my surgeon about it and she addressed it. Between my venting and her stepping in, my paperwork was submitted to the insurance. I am open to speaking to the manager, I am just going to see how the scheduler handles this process now.

I really hope that once it is submitted I can move forward with an approval. I will keep this updated. Thanks again.

[peteyrulz 82]

Since you have the documentation, hopefully it will be smoothe. There are lots of people that have to appeal and are successful doing so.

As far as the doctor's office goes, I would suggest meeting with the office manager to share your concerns. Also, I would suggest writing a letter to the insurance company detailing your weight loss efforts and attaching the documentation anyway! That way you can be sure they have the information and gives you some leverage.

Good Luck

Excellent advice! wish I had followed through with this in my case. Thru a comedy of errors in the surgeon's office staff I am still dealing with this & my denial since Jul 2014. I dare say my surgeon's office dropped the ball, and it has cost me a lot of time. Oye!

I wish I had been more proactive by going directly to the office & dealing with this head on. My insurance is BCBS Fed emp (Anthem)

Edited February 13, 2015 by peteyrulz

[BeagleLover 1,020]

@@Jrs_lovely1, unfortunately, with some people, you have to nip at their heels to get things done.

Edited February 13, 2015 by BeagleLover

[Sharon1964 2,530]

I am the office manager for a medical practice (pain management). I definitely want patients to come in and sit down with me and tell me what's going on if one of my staff is either not doing their job or is giving out incorrect information.

I would encourage anyone having this sort of problem to do the same. They can't do a better job for the next person if they don't receive correction and/or additional training.

[Jrs_lovely1 12]

Quick update:

My surgeons office submitted the documents needed in a timely manner. YAY! BUT now I am getting conflicting information.

I contacted members service to find out if they received the documents and they stated that they had but that the authorization request had been cancelled???? They stated that they sent this information to my Dr.

I contacted my Dr.'s office and they said they had no knowledge of the cancellation and recently submitted the documents.

I called the authorization dept. for my insurance (they wouldn't really talk to me as the patient) and they stated that it was cancelled because I did not meet the requirements. They also stated that they sent notification to the Dr.'s office on Feb 2nd. This time frame is in line with the denial.

I assumed that they cancelled it before they received the supporting documents.

I contacted my Dr.s office and told them all of the information in which I was able to discover and they said that the would follow up.

I am a bit discouraged but still going to hang in there and do what I can to pursue this. I don't understand all of the issues though. I was a hopeful of a smooth process.

[BeagleLover 1,020]

@@Jrs_lovely1, I hear you about the disjointed info you've been getting. Could it have been denied because your BMI is less than 35?

[bamagirl 31]

Playing the ridiculous insurance game is very frustrating! Don't give up!!

[Jrs_lovely1 12]

Got my approval today!!!!! I'm do excited & relieved yet a tad bit anxious/nervous. Part of me thought this day would never come. So glad it did!

[Jrs_lovely1 12]

@@Jrs_lovely1, I hear you about the disjointed info you've been getting. Could it have been denied because your BMI is less than 35?

Hi! I totally missed this post. My current BMI is less than 35; however, I had a higher BMi at the time of submission. I also have co-morbities so the denial was based on lack of supporting documents

[peteyrulz 82]

Congratulations!! Your perseverance certainly paid off.

That's GREAT news!

[Jrs_lovely1 12]

Thank you so much! I was so happy to hear those words of "you have been approved!" I almost cried.