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I need help appealing to my insurance company... again.

post #1 of 4
Thread Starter 

In January I got a letter denying my midwife in network consideration so I wrote them a letter to appeal. I really put a lot into it and really thought there was no way they could say no to me. A couple weeks ago I got a letter denying my appeal. According to my benefits, they can accept or deny any out of network provider as in network for any reason they please. If I'd like to I can write a letter stating my position and they'll call me within 30 days to set up a phone conference.


My husband works for Starbucks and we have Premera Blue Cross, based in Washington. I am really stumped as to what to put in my level 2 appeal. Do I need to put the same information as my first letter? Should I just do a recap of what my first letter said? My midwife is only going to bill them $3400, I'll need to finish up my deductible, a little under $200, and then pay 30%. I never put specific numbers into my first letter (I basically just mentioned it'd be cheaper), should I do that this time? I don't really have numbers or a hospital birth in my area, but I do know that insurance companies make deals with hospitals and sometimes don't pay a cent after the patient pays their portion.


I'm just so confused and overwhelmed and I really need them to consider my midwife in network. Luckily, in the worst case scenario we will only pay her $2200 before the birth. How will we know if we need to do that?! I'm already almost 35 weeks, there might not be much time left to get this all figured out.


I hate insurance companies!!! What's the point of paying those premiums every month if they won't even help me when I need them?!


post #2 of 4

I dont have any advice on what to put in the letters but some things that helped me in with my ins company:


Some insurance companies are more likely to pay *after* the home birth (especially if the midwife uses a billing company). 


Dont give up! I once heard an interview with a former ins comp worker-- She said that ALL claims (requests, etc) that were not "normal" would be declined 3 times before they are reviewed. (My claim, denied 3 times, accepted the 4th. I sent the same info in every time)


Dont give more info than asked for. 



I hope that someone on here can give you more direct help than I did. Good luck to you! And dont give up!

post #3 of 4
Thread Starter 

So would it be appropriate to just send the same letter I sent the first time, but rather than being in response the their first denial have it read in response to the denial of the appeal?

post #4 of 4

I'd appeal again, and check your benefits booklet (called a Summary Plan Description) to find out what the precise appeals process is.  For a self-insured employer, you can write an appeal to the company's benefits committee after the insurance company declines the request - that way, someone at your husband's employer is actually looking at the claim and the people on those committees aren't all insurance or benefits specialists, they're from a broad range of backgrounds and may take the dollars and cents of your claim into account.


For benefits committee review, names are removed, so don't worry about anonymity - the head of the committee will know who you are (because that's who will receive your appeal), but the committees (at least the ones I've worked with) never know.

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