Maybe OT: Any advise on writing an appeal to insurance?

leejgbt wrote:I can help you with this. I have been in this industry for 26 years as well as being an insurance agent for seven years. There are several questions you will need to answer first:

codinqueen wrote:I have UHC Choice, considered an EPO plan (kind of like a picky PPO), and they cover ONLY in-network costs. If I go out of network for medical care, I am paying it 100% BY MYSelf! MAKE SURE BEFORE USING ANY PROVIDERS THAT THEY ARE CONSIDERED IN-NETWORK to get the most bang for your insurance premium buck. [/quote="codinqueen"]
and

codinqueen wrote:Did you verify that the Dr you saw was an "in-network provider" BEFORE you visited him the first time? If you were told he was, do you have the date and time, and name of the person you spoke to at the insurance company telling you he was IN-network? [/quote="codinqueen"]

I had no reason to doubt that this doctor would be considered in-network, since every doctor of any kind I have seen within this "group" of clinics have ALL been covered as in-network, including two previous specialists (of the same kind as this one).

codinqueen wrote:I am pretty skilled at writing appeal letters, used to write them routinely at the Dr office where i was employed as a coder, but you are kind-of an "odd-one-out". [/quote="codinqueen"]

Story of my life! I'm taking Madalot's stance...I'm an enigma!

[/quote="codinqueen"]You could send the EOB showing that they paid the first time around and explain that since the first visit was paid as in-network, your hope is that they should cover the 2nd visit, since you were not aware the Dr was no-longer In-network. Most insured people do not check the provider list for in-network providers before EACH and EVERY Dr. visit, and it is unfair of your insurance company to expect you to do that, after THEY are the ones who processed the first claim erroneously, leading you to believe he was IN-network, due to THEIR error. ALso, I think you will need to change to one of their IN-Network providers for future care, unless you can convince the insurance company that your continuity of medical care will suffer, and therefore your health may decline, if you are not permitted to continue medical treatment with the same Dr. Worst they can do is say "no" as to paying as in-network care, and continuing to cover this Dr for you as an IN-network provider, by special arrangement. If you get a special arrangement from the insurance co to allow you to continue to see this DR, get the agreement in WRITING, print it, and keep it for future problems if any arise. Good luck!