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Posted on: Mon, Jul 7 2008 12:35 PM
Posted by: cvml98 Posts: 38
I have been denied a claim for a standing frame by my HMO insurance but I am appealing the denial claim. I have lots of information and case studies on the benefits of standing (I’ve been doing it for 25 years religiously) but I’m wondering if anyone has faced this situation and how did you approach the appeal. Any input from doctors and/or rehab specialists would be appreciated. Thanks!
Posted on: Mon, Jul 7 2008 9:35 PM
Posted by: Whitney Posts: 679
I used to work for medical insurance companies so I might be able to help a bit. What was initally sent to your insurance company? Just the prescription and the invoice or claim form for the cost? And when you received your denial back, what exactly did they say was the reason for their denial?
All this is extremely helpful in know what your next step is. Most insurance companies will deny anything off the bat that is not specifically stated in their list of covered DME. But I wouldn't worry too much if the initally submitted paperwork was minimal. That's a good thing, and further input from your doc or rehab specialist and any supporting documentation will be very helpful on the appeal. Just don't give up. And you also have the ability to speak directly with the RN case manager reviewing your case. Finding that who that is once the appeal is in review helps because a word from you AND your doctor can make a world of difference.
Posted on: Tue, Jul 8 2008 10:30 AM
Scrappywheels – Thanks for the reply. The original claim was from my PCP as I had asked him to provide a prescription to the DME department for the Standing Frame. I was specific in the type of standing frame I was requesting as I have researched what is out there and found what would work best for me at the lowest cost. (He did send the prescription to DME at my request) In the denial letter they state that the item (standing frame) is not covered by the DME benefit. I will certainly follow some of your recommendations and thank you again for your advise.
Posted on: Tue, Jul 8 2008 5:52 PM
Ok, since their reply was what I expected, its now time for you to prove to them that the payment for this is in your upmost health interest. I would first start by writing a formal letter directed to the case management department/appeals department of your insurance company. I would call first and ask where a such a letter would be directed to. Also, please make sure to not only put in the address field of the letter but the envelope Attn: Appeals - gets it there 9 times faster than if it got stuck in general intake. Explain in your letter the reason you feel that a standing frame would improve your health or be a necessity to your healthcare. I would also obtain an invoice from the DME provider that you will be purchasing the frame from and specifically tell them that it needs to include the HCPC code (or in insider-speak - hick-pick code) on the invoice. Include a copy of that with the letter as well as a letter from your doctor explaining his medical necessity reason as well as any supporting documentation, such as clinical trials, medical journal articles and any part of your medical file that would be appropriate to prove that this frame would greatly improve your quality of life.
If it gets denied again after all that, then I would get the case manager on the phone and conference call with the doctor. You have several appeal levels and the desicion doesn't usually stay with the same individual once you've requested additional appeals. Usually the process goes, a claims processor or intake coordinator in the case management does the initial denial based on a set list of HCPC codes. These folks are only doing what they're told to do and don't generally have any decision making power. Then it goes to a case manager, usually an RN, and then to her supervisor, also usually an RN, and then if things get really down and dirty it ends up in the lap of the Medical Director, who is an MD but of random specialty, usually internal medicine or ortheopedia.
The squeaky wheel usually gets the grease and so if you persist, you might be able to get them to pay for it. I'm never going to guaruntee anything, though.
Posted on: Wed, Jul 9 2008 12:35 PM
Great advise and thank you so much for helping! Your experience in dealing with the bureaucracy is exactly what I was hoping to find here. I can be a squeeky wheel and since I even work for this HMO (in IT) I can get insider info sometimes. Anyway....thanks again and I'll keep you posted on the outcome if you are interested.
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