Insurance covered 100% of my home birth and here is my letter (UnitedHeathcare)

[ifms457]

I wanted to share this letter with anybody that is trying to get their home birth covered by their insurance  After the denial of my first home birth I learned a lot and was able to get my second home birth covered at 100%. Also, here are a few tips that I learned:

• keep notes of every time you call the insurance company
• find out if there are any CNM in-network.  Call them up and find out if they attend home births.  If not, apply for a "gap exception" for your CNM to be considered in-network. 
• keep the letter pretty straight forward with facts and use the insurance lingo that your company uses

• appeal!  This appeal was sent 8 days before my son was born as a last ditch effort and it paid off.

May 20, 2010

Member #: XXXXXXXXX

Group #: XXXXX

United Healthcare Member Inquiry/Appeals

PO Box 30432

Salt Lake City, UT 84130-0432

Subject: Second Level Pre-Service Appeal

Dear Appeals Coordinator:

I am requesting coverage from United Healthcare for midwifery services from an out-of-network provider, Jackie Griggs, Certified Nurse Midwife (CNM) of Gentle Care Birth Services.  The single reason for my request is to enable me to have a home birth.

My attempts to find a practicing midwife in-network have been unsuccessful.  The only name of a midwife that your representative was able to provide me on Friday, October 23^rd, 2009 during our 1:30pm phone conversation was XXXX XXXXX.  After many phone calls to track her down I discovered that she does not even practice as a midwife and is involved in academic research at Baylor College of Medicine.

Jackie Griggs, my midwife of choice, will provide all of my prenatal care, part of which includes home visits, attendance at labor and delivery in my home, and finally, postpartum care for me and my newborn child.  I encourage you to visit her website (http://www.houstonmidwife.com/index/component/option,com_frontpage/Itemid,1) for her philosophy of care and outstanding credentials.   She was my midwife for the birth of my first child and both as a client and a Registered Nurse, I have full confidence in her professional abilities.

My first appeal for a gap exception to be granted for J. Griggs, CNM was denied on the basis that United Healthcare has in-network physicians providing obstetric care (Denial Notification Number XXXXXXXXX).  However, none of them provide the service that I am requesting—a home birth.  A home birth is not an unreasonable request on my part for many reasons:

• I am in the final weeks of a normal, healthy pregnancy with no complications and overall excellent health, which makes me a low risk pregnancy.
• A 2005 study in the North America British Medical Journal found that “planned home births for low risk women in the United States are associated with similar safety and less medical intervention as low risk hospital births BMJ  2005;330:1416 (18 June) http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
• The average hospital birth cost thousands of dollars more than the $3,400 “reasonable and customary home birth/birth center” charges allowed by Unites Healthcare (Global Maternity Care code 54900).  According to your treatment cost estimator tool on your website, the estimated treatment cost for the delivery of an infant through the vaginal canal is $5,467-$6,813.    

Please honor my request for a home birth allowing coverage of Jackie Griggs, CNM.  Please feel free to contact me at [e-mail] or XXX-XXX-XXXX.

For your reference, Jackie Griggs contact information is as follows:

XXXXXx

XXXXXX

XXX-XXX-XXXX

Regards,

[gemasita]

Thanks for sharing this.  I just got my denial from BCBS because they claim their are in-network providers.  So my letter is like yours in that I'm providing evidence that no in-network providers do home births, which is a difference service than hospital births.  I'm hoping I'll get everything right in the first letter so that I don't have to do a second appeal.  It SEEMS pretty straight-forward to me that I'm providing exactly the information they need to approve me but I'm trying not the jinx myself!  Hoping they don't keep denying me just to see if I give up.  I'm glad to know that your letter worked.

[lyndie]

I also have BCBS & a question - did your midwife submit the claim early to BCBS?  I'm asking because mine doesn't submit until after the birth.  This has me wondering if I should be doing something now...

Originally Posted by gemasita 

Thanks for sharing this.  I just got my denial from BCBS because they claim their are in-network providers.  So my letter is like yours in that I'm providing evidence that no in-network providers do home births, which is a difference service than hospital births.  I'm hoping I'll get everything right in the first letter so that I don't have to do a second appeal.  It SEEMS pretty straight-forward to me that I'm providing exactly the information they need to approve me but I'm trying not the jinx myself!  Hoping they don't keep denying me just to see if I give up.  I'm glad to know that your letter worked.

[fujbeck]

Thank you for this! I have BCBS right now but starting in January I will have United Healthcare and our homebirth will be probably in May.

[labortrials]

I'll add that if you're facing a hospital ban or can't find a provider to honor your birth choices (i.e. VBAC), this should go into your appeal letter.  That's my plan anyway.  Even though ACOG revised its position on VBAC and VBAmC, the OBs in our town just don't do it.  Since I can't find an OB with whom I'd be willing to work, and this reasonable request is not met due to tribal obstetric and/or defensive obstetric practices, I need to work with a provider who can provide the service I need and my baby deserves.  :)

[gemasita]

Originally Posted by lyndie 

I also have BCBS & a question - did your midwife submit the claim early to BCBS?  I'm asking because mine doesn't submit until after the birth.  This has me wondering if I should be doing something now...

Originally Posted by gemasita 

Thanks for sharing this.  I just got my denial from BCBS because they claim their are in-network providers.  So my letter is like yours in that I'm providing evidence that no in-network providers do home births, which is a difference service than hospital births.  I'm hoping I'll get everything right in the first letter so that I don't have to do a second appeal.  It SEEMS pretty straight-forward to me that I'm providing exactly the information they need to approve me but I'm trying not the jinx myself!  Hoping they don't keep denying me just to see if I give up.  I'm glad to know that your letter worked.

 

My midwife originally told me that she submits claims after the birth because BCBS needs a service date.  When I asked about this on the phone, they said that would guarentee that my claim would be denied. I assume you have to show that you are being proactive - just like with a pre-approval - and deal with it as soon as you can in the pregnancy.  I'm glad I called or I would have assumed that I could do all of this after the birth.  They gave me a phone number for my midwife to call and she did.  They said she needed to call because they would need info from her that I wouldn't have and they would also have her "version" of what I am requesting.

[Graceie]

I just have to say whoo hoo !!!!!!

[lyndie]

Quote:

Originally Posted by gemasita 

When I asked about this on the phone, they said that would guarentee that my claim would be denied.

I've heard BCBS "isn't the best" but good grief!  I'll definitely be getting an early start on this now.  Thanks for sharing your experiences, mamas.

[Climbergirl]

My midwife has billed with Aetna and doesn't bill until afterwards.  I hate they all have different "rules".

[junebug2011]

Thank you so much! What a service to us :)

[alireb]

Originally Posted by lyndie 

Quote:

Originally Posted by gemasita 

When I asked about this on the phone, they said that would guarentee that my claim would be denied.

I've heard BCBS "isn't the best" but good grief!  I'll definitely be getting an early start on this now.  Thanks for sharing your experiences, mamas.

Lyndie - who is your midwife?  I'm also in MD and have BCBS.  My policy does cover midwives but the homebirth CNM I am considering would be out of network so only covered at 80%.  She also won't submit until after the birth and she wants the whole amount up front by 36 weeks which scares the crap out of me!!

[JosieAK]

I have United HealthCare and I there are NO in network providers AT ALL where I live (I'm in Alaska).  Does anyone know what they would do in that case?  They HAVE to pay something, right?

[ifms457]

It is my understanding that since there is a gap in the service that United Healthcare is offering (and you are paying for), they have to grant a gap exception to give you a provider of some sort. I think that I remember my midwife saying that some of her clients living in more rural areas got their insurance companies to pay for deliveries since a midwife was the provider of their choice and no other OB's were available in-network.  Good luck!  

[pearl2]

My DH is going to FREAK OUT if BCBS denies this. Calling tomorrow to get the ball rolling!

[greenmama66]

Here where I live- BCBS and Cigna are the 2 companies that pay out but the midwives have to submit claim after the birth. And they like the baby separate on separate claim so the midwives here send it out 6 weeks after the birth and after they have done all the visits afterwards and so on. % of what one get's back varies I was told from 60-80 % which is pretty good .Most HB MW's here charge from 3000- 3300 per birth but bill insurance for about 12-13 grand because clients are getting a discounted cash price.

[gemasita]

So I just got a denial of my appeal through BCBS.  This first denial was based on them saying that there ARE in-network providers available.  So I sent a letter to prove that none of the in-network providers do homebirths, only hospital births.  Thought that would be pretty straight-forward.

The denial of the appeal said "not medically necessary."  It said that it was denied because using a midwife and having a homebirth are preferences and that there is a hospital within a reasonable distance from me that provides delivery services.

Anyone come across something similar?  I didn't think they could change the reason for denial.  But if they can, then do I have to go into a whole thing about OBs versus midwives and homebirths vs hospital births?  I'm saving them money - sheesh!

They've covered homebirths for other people I know.  Is that an argument?

[frenchkissed]

Tell BCBS that using a hospital is not medically necessary.  Geez! You are saving them so much money!  OK vent over.

You have not already had the homebirth, correct?  (Your sig says due in January)  There is definitely still hope.  If the midwife you are using has the credentials a hospital midwife does (i.e. CNM) and that type of midwife would be covered, you have a good chance of getting your homebirth covered. 

What kind of BCBS plan do you have?  I live in NY where CNMs have to be covered by law, but I was still subject to the in-network/out-of-network stuff which greatly affected what I would have paid. Of course they had in-network midwives in the area, but ("of course," again) none who attend home births.  My insurance is a BCBS of Illinois PPO and I applied for and was awarded a PPO Waiver from BCBS so they covered my homebirth at in-network rate (80% after I met my $1000 deductible). They paid for $2800 of my $4200 homebirth bill. Then my midwife billed BCBS separately for some newborn services and my Rhogam so I actually didn't owe her the full $1400 in the end (I had to prepay 1500 of it so I actually got a little refund).

Good luck!

[frenchkissed]

Tell BCBS that using a hospital is not medically necessary.  Geez! You are saving them so much money!  OK vent over.

You have not already had the homebirth, correct?  (Your sig says due in January)  There is definitely still hope.  If the midwife you are using has the credentials a hospital midwife does (i.e. CNM) and that type of midwife would be covered, you have a good chance of getting your homebirth covered. 

What kind of BCBS plan do you have?  I live in NY where CNMs have to be covered by law, but I was still subject to the in-network/out-of-network stuff which greatly affected what I would have paid. Of course they had in-network midwives in the area, but ("of course," again) none who attend home births.  My insurance is a BCBS of Illinois PPO and I applied for and was awarded a PPO Waiver from BCBS so they covered my homebirth at in-network rate (80% after I met my $1000 deductible). They paid for $2800 of my $4200 homebirth bill. Then my midwife billed BCBS separately for some newborn services and my Rhogam so I actually didn't owe her the full $1400 in the end (I had to prepay 1500 of it so I actually got a little refund).

Good luck!

[gemasita]

Thanks for replying frenchkissed.  Correct - I haven't had the homebirth yet - I'm due in Jan.  They told me on the phone that I needed to apply for the in-network exception before the birth, if possible, so they could get started on it or whatever.

It's BCBS of North Carolina BUT...it's the State Health Plan, for state employees.  So I know that there are *some* things that are different from all the other plans.  But they DO cover CNMs and my homebirth midwife is a CNM.

The original denial was me trying to get an in-network acception because, like you said, of course there are CNMs in network but none do homebirths.  So I just had to show that there were no in-network providers doing homebirths.  That's why I'm stumped - I gave them the documentation to back up my exception but now they have changed the argument.  I guess I need to argue that hospital births and hiring surgeons to assist at births is certainly not medically necessary for a normal, healthy pregnancy.  But I'm confused as to whether that's actually what I need to argue because they changed the reason on me.  Can they do that?

[frenchkissed]

*Shrug* I don't know if they can do that... maybe they can't, legally but they are banking on you not following up?  I thought the original letter in this post was excellent, maybe you could point out to them how much money you're  saving them, as if that were the point!