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Trying to understand Ins. Company's denial
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<blockquote data-quote="bigblueagain" data-source="post: 4116" data-attributes="member: 909"><p>yep. I hate to tell you but most carriers consider "rehabilitation" benefits as eligible for only what is considered short term acute accident or illness.( and rehabilitation in this case includes Occupational Therapist (OT),PT and speech normally). The type of problems you are describing are often considered under a development disorder, which is and of itself not necessarily considered a "medical" diagnosis. Having said that, there are a couple of things you can do. Very first thing is to call the Customer Service for Regence and ask for the "appeal" process in regards to decisions based on 1) benefits and 2) medical necessity. I believe you might have a better chance if you go the medical necessity route. IF this is an HMO they have to have expedited appeal processes in place. Again this will be noted in your benefit booklet. The reason you call CS is that they should document your call, which should put them on notice that you will be appealing. Then you also need to ask who exactly will be doing the review. Most first level appeals for medical necessity go to the medical director of the carrier. Many times they do not have the expertise in the area of therapy being requested. In such case most carriers now have subspeciality boards where like type physicians of those who ordered the therapy will be reviewing the request. You should submit as much supporting documentation as possible. If they can't give you the name of the specialist who will review, or if it is the medical director for the carrier, then ask what the second level appeal process is. You may have to go thru several levels. Most of the time, if you still don't agree with their findings, you probably will be able to ask for an independent review by an outside agency. It sounds like the plan is a fully insured ppo however, and usually the employer does not go out of the benefit boundaries. This has to do with the risk and also what is called reinsurance. Your son also does not have a life or death type of request, so expect it to take some time. I would also encourage you to start looking to the school district.....I really don't think you may win this one. But if you go in with some of the questions as above, at least they will know that you aren't the typical consumer who just takes no lying down. Let me know what you find out. BLUE</p></blockquote><p></p>
[QUOTE="bigblueagain, post: 4116, member: 909"] yep. I hate to tell you but most carriers consider "rehabilitation" benefits as eligible for only what is considered short term acute accident or illness.( and rehabilitation in this case includes Occupational Therapist (OT),PT and speech normally). The type of problems you are describing are often considered under a development disorder, which is and of itself not necessarily considered a "medical" diagnosis. Having said that, there are a couple of things you can do. Very first thing is to call the Customer Service for Regence and ask for the "appeal" process in regards to decisions based on 1) benefits and 2) medical necessity. I believe you might have a better chance if you go the medical necessity route. IF this is an HMO they have to have expedited appeal processes in place. Again this will be noted in your benefit booklet. The reason you call CS is that they should document your call, which should put them on notice that you will be appealing. Then you also need to ask who exactly will be doing the review. Most first level appeals for medical necessity go to the medical director of the carrier. Many times they do not have the expertise in the area of therapy being requested. In such case most carriers now have subspeciality boards where like type physicians of those who ordered the therapy will be reviewing the request. You should submit as much supporting documentation as possible. If they can't give you the name of the specialist who will review, or if it is the medical director for the carrier, then ask what the second level appeal process is. You may have to go thru several levels. Most of the time, if you still don't agree with their findings, you probably will be able to ask for an independent review by an outside agency. It sounds like the plan is a fully insured ppo however, and usually the employer does not go out of the benefit boundaries. This has to do with the risk and also what is called reinsurance. Your son also does not have a life or death type of request, so expect it to take some time. I would also encourage you to start looking to the school district.....I really don't think you may win this one. But if you go in with some of the questions as above, at least they will know that you aren't the typical consumer who just takes no lying down. Let me know what you find out. BLUE [/QUOTE]
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