So pissed--insurance denied my gap exception - Mothering Forums

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#1 of 14 Old 02-03-2009, 07:03 PM - Thread Starter
 
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The rep told me that they had a Nurse Midwife in network but she doesn't do homebirths. But they consider Homebirths a "personal preference" so therefore they were denying my request.

JERKS!!!

I WILL be appealing this! How can you say that Homebirth is a covered benefit but then not cover any providers in network???

~ deb, BFAR mommy to ds1 Dec 7, 2003, Jan 08, ds2 Sept 20, 2009
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#2 of 14 Old 02-03-2009, 07:07 PM
 
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That IS crap. So they are saying - in theory, at least - that they would only cover it if it was deemed medically necessary to birth at home? (Which we all know no medical doctor is going to cut his own throat and do that).

And ... HELLO insurance companies ... it's CHEAPER!!!

Homeschooling mama to 6 year old DD.

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#3 of 14 Old 02-03-2009, 07:09 PM
 
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Oh I think I get it. They are saying they have plenty of providers in network. And therefore if you have a personal preference - like, maybe you want a female OB, or an Asian one - then too bad, they have provided an adequate selection and you gotta pick. And they're saying that if none of their providers do home births, then same thing, you have to pick from their "adequate" list of providers.

Homeschooling mama to 6 year old DD.

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#4 of 14 Old 02-03-2009, 07:10 PM
 
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A pox on them all the same.

Homeschooling mama to 6 year old DD.

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#5 of 14 Old 02-03-2009, 07:19 PM - Thread Starter
 
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yeah, I tried to tell him that giving birth in a hospital was also a personal preference, but he wasn't buying that.

GRRRR!

~ deb, BFAR mommy to ds1 Dec 7, 2003, Jan 08, ds2 Sept 20, 2009
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#6 of 14 Old 02-03-2009, 07:43 PM
 
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Who is your insurance? I'm dealing with the insurance co. right now. Long story short on my side, they want my mw to be put in their provider list so they can check her credentials, then we need to put in Gap EX.
I'll be following your story since I might be on your road soon enough. Pls, keep me updated and hopely they can reverse after reviewing your appeal!
Preggo or post partum moms don't need this stress. (I read in my benefit book that Grievance form must be filed within 1 months of service lendered...)

 ~ Have a Blessed Day!
DS 6/2002, DD 5/2006, DS Feb 2009
familybed1.gifhomebirth.jpgtoddler.gifecbaby2.giffemalesling.GIFhomeschool.gif
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#7 of 14 Old 02-03-2009, 08:49 PM
 
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I'd talk to a midwife, they are really good at coding and have gotten insurance to cover things by using different codes.
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#8 of 14 Old 02-03-2009, 10:57 PM - Thread Starter
 
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Quote:
Originally Posted by naturallyspeaking View Post
Who is your insurance? I'm dealing with the insurance co. right now. Long story short on my side, they want my mw to be put in their provider list so they can check her credentials, then we need to put in Gap EX.
I'll be following your story since I might be on your road soon enough. Pls, keep me updated and hopely they can reverse after reviewing your appeal!
Preggo or post partum moms don't need this stress. (I read in my benefit book that Grievance form must be filed within 1 months of service lendered...)
I have United Healthcare PPO.

~ deb, BFAR mommy to ds1 Dec 7, 2003, Jan 08, ds2 Sept 20, 2009
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#9 of 14 Old 02-04-2009, 11:39 AM
 
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Quote:
Originally Posted by deymm View Post
The rep told me that they had a Nurse Midwife in network but she doesn't do homebirths. But they consider Homebirths a "personal preference" so therefore they were denying my request.

JERKS!!!

I WILL be appealing this! How can you say that Homebirth is a covered benefit but then not cover any providers in network???
I am right there with you!!! I applied & was told that since they cover CNM's working under a DR that they will not cover her....even though I was told last Dec that SHE WAS COVERED!!!!!

I am currently working w/ my DH's HR dept. to see if there was a change in policy....but from what she told me there was not (double checking to verify). My personal feelings here ~ the first person who spent over 30 mins checking things for me on the phone was not a nurse.....the second person who then denied my claim ~ they are nurses who decided what gets covered for gap extensions....KWIM?

I did explain to the nurse that they saved over 50% by paying for TWO homebirths already for me....and they were not paying the hosp for me to stay there since my house will not bill them

I was told also that I could appeal it after the birth coverage is denied.....yea, just what a new momma wants to #$#$# deal with!!!!

Dana
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#10 of 14 Old 02-04-2009, 03:07 PM
 
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Quote:
Originally Posted by deymm View Post
I have United Healthcare PPO.
I have United Healthcare also. My homebirth was covered out of network. While on paper it was supposedly 60% coverage. In actuality our out of pocket was only about $300. Our midwives billed for some newborn exams and home visits and got them to pay for the majority of their fee. Our midwives are CPMs.

Heather Mike Married 8/1/99 Mom to Charlotte Aug 04, Nov 06, and Katherine Oct 07
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#11 of 14 Old 02-04-2009, 06:16 PM - Thread Starter
 
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Quote:
Originally Posted by Belle View Post
I have United Healthcare also. My homebirth was covered out of network. While on paper it was supposedly 60% coverage. In actuality our out of pocket was only about $300. Our midwives billed for some newborn exams and home visits and got them to pay for the majority of their fee. Our midwives are CPMs.
Good to know. In IL you have to be a CNM or OB to attend a birth, in hospital or at home. The only CNMs in their network do hospital births only.

My MW uses a third party billing service, so we'll see what they can do.

~ deb, BFAR mommy to ds1 Dec 7, 2003, Jan 08, ds2 Sept 20, 2009
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#12 of 14 Old 02-04-2009, 06:48 PM
 
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Private health insurance that pays for maternity care has to pay for birth regardless of where it occurs unless it is specifically written in the policy that home birth or birth center births are excluded. If your provider is legal to practice in your state they cannot be denied payment (though it may be at an out of network rate).

Quote:
http://frwebgate.access.gpo.gov/cgi-...1999&TYPE=TEXT
Code of Federal Regulations Title 45, Volume 1:

(iii) Attending provider defined. For purposes of this section, attending provider means an individual who is licensed under applicable State law to provide maternity or pediatric care and who is directly responsible for providing maternity or pediatric care to a mother or newborn child.

c) Construction. With respect to this section, the following rules of construction apply:

(1) Hospital stays not mandatory. This section does not require a mother to--

(i) Give birth in a hospital; or

(ii) Stay in the hospital for a fixed period of time following the birth of her child.

(2) Hospital stay benefits not mandated. This section does not apply to any group health plan, or any group health insurance coverage, that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child.
http://www.gentlebirth.org/cgi-bin/q...&maxresults=40

http://www.gentlebirth.org/archives/money.html#HMO

http://www.texasmidwives.com/

Quote:
Here are some links leading to the parts of Title 45 I quoted:

Googled "Code of Federal Regulations", clicked on it, picked Title 45 from the drop down menu, picked Volume 1 - subtitle A - 1to199, clicked 146 Requirements for the Group Health Insurance Market, clicked 146.130
Standards relating to benefits for mothers and newborns., Clicked on Subpart C,

http://ecfr.gpoaccess.gov/cgi/t/text...l=%2Findex.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...5/45tab_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...45cfrv1_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...46_main_02.tpl

http://ecfr.gpoaccess.gov/cgi/t/text...3.33.1&idno=45

http://ecfr.gpoaccess.gov/cgi/t/text...dno=45;cc=ecfr

"It should be a rule in all prophylactic work that no harm should ever be unnecessarily inflicted on a healthy person (Sir Graham Wilson, The Hazards of Immunization, 1967)."
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#13 of 14 Old 02-04-2009, 07:02 PM - Thread Starter
 
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Oh, they will pay out of network, but I want them to pay IN network! It's WAYYYYYY less!

~ deb, BFAR mommy to ds1 Dec 7, 2003, Jan 08, ds2 Sept 20, 2009
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#14 of 14 Old 02-04-2009, 07:06 PM
 
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THe only reason I got my HBMW covered in network is becaseu there were absolutely NO MW's in their plan at all. It is still going to cost us $ though.

W (26) and C (27) parenting G (11/06 ) and D (2/09 ) plus a new one (3/11)
Sometimes the greener grass is actually AstroTurf, a false promise and nothing more.
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