How Tonya Should Go About Appealing Her "Elective" Miscarriage

I just read the story ‘Blue Cross Blue Shield Calls Miscarriage “Elective Abortion,” Denies Claim’, and I work for BCBS in NY. From what I’ve learned (and this is just from my experience working for a year there). The best thing for Tonya to do is appeal. She should write a letter explaining what happened that night. Go to the hospital get medical records/Doctor reports/emergency reports anything that shows 1) the medical necessity of the services and 2) what exactly happened. In NY there is a 180 day time limit from the last time the claim was adjusted (but that may be different in her state). Also, in NY, there are at least 2 appeal levels (three technically, and sometimes 4) Here’s how it works for the account I work for…

(again, definitely different for different plans, if you call the customer service number, they’ll be able to advise you on exactly how this works) A customer calls up, says they disagree with how a claim is processed. If there’s something I can do, I do it (call the dr’s office to get a different dx code, med recs, whatever) If it’s something that’s blatantly wrong, I can send it to appeals to have it fixed. If that doesn’t work, and the customer disagrees with what I’ve found, I can still send it to adjustments for the Standard Inquiry. (this is a proto-appeal) it takes 14 days (generally) The member is sent either a new explanation of benefits (if the claim is adjusted), or a letter saying (sorry, the claim is right). On to round two, which is technically Appeal-1. This has to be done in writing. It takes 30 days to process, and the member gets either the eob, or the letter, on to round three, Appeal-2, same idea 30 days to process, member gets the eob or the letter.

If that doesn’t work, the next step (at least for the plan I cover) is one last appeal, which gets sent, not to BCBS, but to the company that the member works for. They review it there, same 30 days for processing, and they send the member a letter. I don’t know if this is typical (there’s a lot of chances for claims to be changed here), but the general process is the same.

The best thing I can tell you guys, is send as much information as you can gather, ER records, pathology reports, doctor notes, peer reviewed literature, whatever you can find to prove the medical necessity of the service. I gather from the difficulties that are put up around it, that insurance companies don’t want people to try this, but it’s worth it, and it’s worth going through the entire process as well.