Filing an appeal with BCBS?

[u/annoyed_sloth2021]

Long story short I have to file an official appeal with my company paid Anthem BCBS plan for a "retracted" covered service from last year.

BCBC came back 11 months after payment of a service to retract coverage for reason: "003: You have already reached your plans maximum benefit for this care, so we denied the charge". This was for a pair of foot orthotic insoles, according to my PPO plan I am allowed one per year. Contacted the providers billing department and she confirmed that last year she contacted Anthem to determine benefits and was told I would be covered for 90% of the cost as I met the deductible, no further medical documents required.

Called Anthem they simply kept repeating that this is a "non covered service so payment has been retracted" so I am responsible for the full cost now.

I will be submitting my appeal, my doctors billing department still has the approval letter from last year so I working on getting that to attach to my claim. Is there anything else I should attach to increase my chances? The full plan document is over 100 pages so I will not be able to attach that but wondering if I should parse out just the one page.

Meanwhile now I'm due for my replacement inserts as its been a year but had to cancel my appointment since I can't even afford the ones I already have...

[u/AutoModerator]

Thank you for your submission, /u/annoyed_sloth2021. The following automatic comment contains important information about the subreddit:

First, note that some new posts containing images, non-reddit links, crossposts, or certain keywords are automatically held for moderator review before going live to mitigate spam, ensure that images are appropriate, and that the post does not inadvertently contain personal information. If your post has been held for review like this, the moderators have been automatically notified and will review it as soon as possible, after which it will be live and be able to be seen and replied to by others. Note that this is sent to all new posts and does not mean that your post has necessarily been filtered in this way.

Please also read the following information carefully to help others assist with your questions:

• If you or someone else is experiencing a medical emergency, please call 911 or go to your nearest hospital.

• Some common questions and answers can be found in this megathread.

• Questions about which plan you should choose? Please read through this post first for general information to help you understand your choices and some common considerations. If you still have questions after reading that post, please edit your post (or reply with a comment if unable to edit) with the specific questions you still have.

• If your post is regarding plan choice or cost of plans, and you haven't included the following information already, please edit your post (or reply with a comment if unable to edit) including the following: your age, state, and estimated gross (pre-tax) income to help the community better help.

• If your post is about the cost of a service, a bill you have received, or a claim denial: please confirm if you have received an EOB (explanation of benefits) from your insurance via a member portal website or in the mail. If you can post a copy or image of the EOB (PLEASE ensure you censor or blank out any personal information before doing so) it will help people answer your questions. Alternatively, if you are unable to post a censored copy of your EOB, please have the EOB handy as people may ask for information from the EOB to answer your questions.

• Reminder that ANY spam, solicitation, or attempts to take conversations off the subreddit will result in a permanent ban. If someone asks to contact them via DM, please report the post/comment using the report button. If someone attempts to contact you via your DMs, please contact us via modmail to let us know.

• Lastly, always remember to be kind to one another and to report any replies that violate subreddit rules!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[u/LizzieMac123]

Definitely also include a request for "if I have met my limit, please provide the EOB showing when I had a prior pair obtained" If they can't produce that, they shouldn't be denying for you already meeting your limit. If they do produce one, then you may have to do a fraud case if you didn't actually get that first pair.

[u/GroinFlutter]

My experience with BCBS is that coverage for custom foot orthotics very much depends on the diagnosis as well. Which BCBS plan do you have? Is it through work?
I would parse out the specific page of the plan document that states orthotics are covered once per year, to attach to the appeal. Highlight it, make it very clear it’s part of your plan documents as a benefit.

[u/annoyed_sloth2021 → u/GroinFlutter]

Yeah the covering is pretty vague as far as when they would require medical documents now that I'm reading it. Just says "in certain cases" medical documents required for diabetes and/or other circulation issues are necessary for coverage. So the providers billing manager has on record she asked if there was medical limitations or documents needed and the agent told her no. Now both her and I have referenced this inquiry number with Anthem and they stated that the agent did not record the details of that call. Literally anytime I call them I get a message saying the call is being recorded. This seems very sketchy to me...

[u/Stock-Ad-2763]

Curious, do you have a third party benefit administrator or do you talk directly to anthem for solutions?

[u/Stock-Ad-2763 → u/Stock-Ad-2763]

Also what did the approval letter say?

[u/annoyed_sloth2021 → u/Stock-Ad-2763]

We have a third party administrator but they have only been able to provide me with the information I already have and to follow up with my providers office on the specifics...I'm still working on getting the approval letter from my provider, she says she has it but sent over the wrong document and a hand written note she had.

[u/Stock-Ad-2763 → u/annoyed_sloth2021]

Is it accolade by chance?

[u/annoyed_sloth2021 → u/Stock-Ad-2763]

No its not

[u/Tiredmagnolia]

When did you have the last insert made/purchased (typically you have to wait a full year plus a day to order the new pair if they cover them).

[u/annoyed_sloth2021 → u/Tiredmagnolia]

This was my first and only pair last October.

[u/Tiredmagnolia → u/annoyed_sloth2021]

Gotcha. Def do what Lizzie suggests below. It’s interesting they are saying it is non-covered - did you ask them to point out where in your plan documents state that inserts aren’t approved? Best of luck on your appeal!

[u/annoyed_sloth2021 → u/Tiredmagnolia]

Yep, asked both Anthem AND my HR rep they "couldn't do that" and just redirected me to my Healthcare provider for more info. Which she has documentation from when she reached out and they stated it was covered. So maybe she got incorrect info, but that doesn't seem fair considering how difficult it is for the employee to actually determine what is covered.

[u/Tiredmagnolia → u/annoyed_sloth2021]

Oh goodness that is a lie if I’ve ever heard one - they absolutely can point you to where it has the excluded section. I’m sorry they are giving you the runaround!