Sample Appeal Letters for Homebirth Coverage - Mothering Forums
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#1 of 46 Old 11-16-2006, 12:24 PM - Thread Starter
 
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I have United HealthCare, and according to my policy I have coverage for midwifery services at a in-network and out-of-network rates. They picked apart my claim and denied all of it. I was wondering if anyone had any sample letters of appeal to their insurance company. I've been reading the gentlebirth.org site for help, but there is only one sample letter and it doesn't really fit my situation. I'm just looking for inspiration and trying not to reinvent the wheel.

Please PM me if you can help!
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#2 of 46 Old 11-16-2006, 12:29 PM
 
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Don't have any letters, sorry, but wanted to offer my support. I used to work for an insurance company and they can be a nightmare. Have you looked into the laws of homebirth in your state? In Florida an HMO has to cover homebirth, for instance. You could call the insurance commissioner and see what they say about it. You can also tell the insurance company you are in contact with them once you find out what the state laws are. That usually gets a fire lit under their rear end because they don't want complaints and possible audits.
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#3 of 46 Old 11-16-2006, 12:31 PM
 
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How was it billed? Try having your midwife bill under a global code and see if it goes through. If not- get on the phone and ask exactly what is wrong and what needs to change on the bill for them to cover it. That's how we got ours covered through UHC.

-Angela
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#4 of 46 Old 11-16-2006, 01:00 PM - Thread Starter
 
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I wonder if the global billing is the issue. Because they had things like this fee is not appropriate for someone of this age, blah blah blah. I think that was the newborn care being billed under my name. I will ask my midwife for a global billing receipt. And get on the phone with UHC in the meantime.
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#5 of 46 Old 11-16-2006, 01:04 PM - Thread Starter
 
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Here's my letter thus far, mostly in the same format as the gentlebirth letter. It's my first rough draft, and I plan to edit/alter it to make it my own a bit more. I'd appreciate any critique anyone has to offer

Dear Sirs:
This is a formal letter of appeal to the above referenced claims. United HealthCare’s denial of my claim for midwifery services contrasts the coverage available according to my policy. There is not a single in-network midwife in my entire state. Midwifery care SAVES United HealthCare money and I am concerned at the denial of my claim when our policy includes coverage.

Please refer in our file to a claim for midwifery services rendered by (midwife) for my baby's birth on 8/13/2006. We believe that the $2,620 fee assessed for my prenatal exams and birth for (midwife) were more than fair for services provided.
Homebirth is a low cost safe alternative to hospital birth. Please see the attached study by the British Medical Journal. Had I elected to have my third birth at the hospital, I would have been a likely Cesarean Section, or other intervention candidate, due to the my previous health history. This would have significantly increased all of our costs by tens of thousands of dollars. United HealthCare should be supporting homebirth for healthy mothers because pregnancy is a normal condition, not a medical condition.
Should United HealthCare be interested in saving shareholders’ money by supporting families who chose a safer alternative to hospital interventions, I refer you to the following for a list of hospital charges for the state of Arkansas (a copy is enclosed):
http://www.arkhospitals.com/arkhospm...mer06stat9.pdf
Based on these hospital estimates for my geographical area that was released in the summer of 2006, by choosing a safe and low cost birth, I SAVED United HealthCare an estimated $3603 for facility charges alone. The facility charges do not include (based on 2003 facility charges for labor and birth):
·additional anesthesia services charge for an epidural - around $2000-$3000.
·additional newborn care charge - up to $5000 [Numerous charges, including nursery fees, pediatrician fees, medications]
·additional maternity provider charge for all births - around $3000-$5000 for the average four hours a doctor spends with you during prenatal care, the birth, and quick postpartum checks during hospitalization.


We expect full and prompt reimbursement for expenses incurred by (midwife). If this claim is denied again, we will undertake the following steps:
1)Our benefits coordinator at X will be contacted.
2)We will file a formal complaint with the State Department of Insurance and Banking.
3)We will attend your annual stockholder meeting to inform United HealthCare stockholders that United HealthCare is not interested in saving stockholders’ money by supporting lower cost healthcare options.
4)We will pursue this matter in small claims court.

Please contact us at X if you have further questions.
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#6 of 46 Old 11-16-2006, 04:49 PM
 
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Personally, I wouldn't bother with a letter at this point. Our experience was that they just sent form denials to anything in writing. We only made progress on the phone. The first time it was rejected our midwife got on the phone and talked to them. Figured out most of it. Then they wanted to reject it because she wasn't a CNM. We called, explained she was "documented" which met tX law. They wanted a copy of her cert. We faxed it. Then they were just sitting on it not doing anything until dh called and bugged them some more. It was hung up because they didn't have a facility code. An hour conversation and being transferred to several different people later and they finally accepted that we didn't have a code for our living room

-Angela
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#7 of 46 Old 11-24-2006, 10:11 AM
 
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Sample letters are available from the American College of Nurse Midwives (www.mymidwife.org) - including letters for homebirth coverage.

This site http://www.peacefulbeginnings.net/Ch.../midwives.html
also has some interesting tips (scroll to the bottom) on getting homebirth covered.

Good information about insurance billing codes is available here:
http://www.birthcottage.com/insurance.html

This article recommends always cc'ing "your employer's plans and benefits person [on your correspondence with yout insurance company] so they have ammunition"
http://www.findarticles.com/p/articl...35/ai_19173884

We did get part of our homebirth (about 1/3) covered by BCBS PPO and submitted the rest of the cost to our flex spending account.
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#8 of 46 Old 11-24-2006, 10:50 AM
 
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Is there any way this can be stickied? This thread has some great links and info for mamas trying to get coverage.
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#9 of 46 Old 11-25-2006, 05:56 PM
 
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These are great resources, thanks. Happy to sticky it!
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#10 of 46 Old 12-27-2006, 05:00 PM
 
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We are going through the process of trying to get our MW care covered through BCBSMA. While BCBSMA has hundreds of 'in-network' midwives, all of them perform hospital-only births. Those we spoke with also work on a rotating on-call basis, meaning that the person I see for months for prenatals may indeed NOT be the person who delivers our child.

My husband & I feel passionately about a home birth. Fortunately my primary care doctor feels the same way (his wife has had 6 home births with a midwife!!), so he eagerly submitted the referal for me. BCBSMA denied it on grounds that they have midwives already, so I don't need to go "out of network".

Below is the letter I sent to the "grievances" department just yesterday in hopes of turning the tide...
Hope this helps others out there - and hope it works for me!! If anyone has other advice, I'd love to hear it!!

--------------------------------
Re: Case #XXXXXX

Dear XXXXXX -

Thank you for providing me with your email address so that I can submit a formal request for my case to be re-reviewed.

As you are aware I am requesting coverage from BCBS for midwife services from a non-participating specialist, namely Deborah Eastman of Home Birth Midwives (http://www.homebirthmidwives.com). The single reason for my request is to enable me to deliver our child in the comfort of our home.

My husband and I spent many hours calling, speaking with and (in some cases) visiting all of the midwives listed in the BCBS network for this region. While many of them seemed well qualified as midwives, none of them provide the service we require - namely a home birth.

Deborah Eastman, our midwife of choice, is a midwife who will provide all of my pre-natal care, part of which includes a home visit; attendance at labor and delivery in my home; and finally postpartum care, also in my home. I encourage you to visit Deborah's website (http://www.homebirthmidwives.com) for her philosophy of care.

My reasons for electing a home birth are as follows:
- I am proceeding with a normal, healthy pregnancy with zero morning sickness and overall excellent health.

- Since pregnancy and birth are natural physiological events, normal birth does not belong in a hospital.

- The natural course of labor is perfect and should be interfered with as little
as possible. At home I will avoid unnecessary medical interventions such as
episiotomy or constant fetal monitoring.

- I expect that with a homebirth, our baby’s birth will proceed gently and
naturally unless a real emergency occurs. If I am transported to a hospital
during my homebirth, statistics indicate that me and our baby are just as likely to have a good outcome as if I had started out in a hospital setting. Many experts believe that our baby and I will have a reduced chance of getting an infection if I am not in a hospital.

- Medical management of pregnancy and birth should be limited to those which are medically complicated. If my pregnancy changes to fall into this category, my midwife will refer me back to my OB/GYN and hospital.

- Unnecessary medical interventions complicate normal labor, creating additional risk and the need for more intervention.

- Comfort and security will help me cope with labor. Comfort and security exist in my home. Women who give birth at home report a greater sense of control over the experience and this sense of control generally contributes to greater overall satisfaction with the birthing experience.

I'd also like to reference a study conducted last year regarding the safety of
home births, based on 5000+ planned home births in North America. You'll find a reference to the study at the Citizens for Midwifery website
(http://cfmidwifery.org/resources/item.aspx?id=85) and the actual study at the British Medical Journal's site
(http://www.bmj.com/cgi/content/full/330/7505/1416?ehom). The study found that for low risk women in the United States, planned home births are as safe as hospital births.

In addition, according to a US-based study by Anderson, et. al published in the Journal of Nurse Midwifery, (44(1):30-5 1999 Jan-Feb), "The average
uncomplicated vaginal birth costs 68% less in a home than in a hospital, and
births initiated in the home offer a lower combined rate of intrapartum and
neonatal mortality and a lower incidence of cesarean delivery." See also
http://web.centre.edu/david/Home%20B...ub%20Draft.doc.

My primary care physician, XXXXXX (Provider # XXXXXX)
wholeheartedly supports my decision for a home birth.

Please honor my desires for a homebirth by allowing coverage of care by Deborah Eastman. Please feel free to contact me at this email address
(XXXXXX) or on my cell XXXXXXat any time. I am now 16+
weeks pregnant with an expected due date of June 9th, 2007.

For your reference, my midwife's contact details are as follows:
Deborah Allen Eastman
83 Inman Street
Cambridge, MA 02139
617-864-3531

Thank you for your consideration,
Aiyana, Michael & "baby" XXXXXX
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#11 of 46 Old 12-30-2006, 09:06 PM
 
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I had a homebirth on March 31st, so it's been 9 months. For various reasons we never submitted a claim but I don't think I'll ever forgive myself if we don't try at least, as money is extremely tight, and why shouldn't they pay?! I've often read that submitting a claim after the baby is born works best, but is nine months later too late? We are in MA and have blue cross blue shield HMO. Any personal experience with this, or words of encouragement?

Btw aiyana - I had a fantastic homebirth with deborah! Do you live in cambridge?
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#12 of 46 Old 01-13-2007, 01:55 PM
 
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TanyaS, i love your letter i think it is perfect. Only so much can be done over the phone in some cases. To advance a claim up the 'chain of command' requires a specific set of steps be taken and it appears to me that you are advancing this claim in the right direction, indeed the only direction you've left to go. Which is, elevating your level of appeal to include official oversight from outside of the insurance company. I wonder how it turned out, do you have any news?

aiyana, also a nicely written argument. You should be prepared, however, to take up this fight once they actually deny your claim. My communication with a billing professional who serves midwives and their clients cleared that up for me right away. I was not going to be successful in securing preauthorization for payment from them. period. (I have BCOI, which is blue cross of Idaho) In fact, she recommended that i not breathe another word about it to BCOI, not tip them to my hand so to speak. What she has found the most success with is fiddling with the billing codes. But if they are watching for that, with an adversarial attitude.... well, you can see how that would not be real good.

I think the most important thing for me to figure out was that if i wanted it badly enough, i needed to be willing to carry those costs myself. Boy, that was not at all what i wanted to hear, but i believe it is true.
There is a good chance of getting reimbursed by the insurance co if you keep at it. If your midwife has a billing professional, all the better -let them do their thing. But, even if that fails you still have a really good chance of convincing your insurance co by yourself. The letter you have written is awesome, but i fear it may be untimely. The time you want to start getting serious with them is after they deny. Then there is a whole procedure for appealing that denial, and you do have some power in that. Then would be the time for kick butt letters like the one you posted, because then you've got the attention of someone who is in a position to approve claims which do not fit the criteria for approval according to 'policy'. Thats when you put on your game face, ykwim?

all you alls gotta let us know how these things resolve!

-anj119
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#13 of 46 Old 01-13-2007, 02:06 PM - Thread Starter
 
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I called at Angela's suggestion, and apparently it was denied because there was services for the baby included with services for me. According to them, I needed to send in two receipts: one for my care and one for the newborn care. And her words were "then it could be processed and covered". So I sent a little note, starting with "according to our conversation...." and new receipts (one of which is only $50 for the newborn care). Now I'm just waiting for their response. If they still deny, then they get the letter I posted before. I'll update when I have news!
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#14 of 46 Old 01-13-2007, 02:32 PM
 
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right on TanyaS. That phone call sure did clear up a lot, didn't it?

I do not mean to discount the value of continuing to communicate with the insurance reps over the phone by my post.

Only to encourage those who have reached an impasse with those who they reach by phone to advance their argument by the submission of letters using the appeals process. It can be very discouraging to have reached what seems like a brick wall, where your communications are no longer fruitful in the way of eliciting new information from the representatives or where your information is no longer effective to cause those representatives to review, again, the possibility of approving your claim.

My intent was to encourage those who have reached that point to use the appeals process. Not to discourage them from productive communications with the insurance reps. Sorry for any confusion.

I will be waiting to hear your news, Tanya! my fingers are x'ed...

-anj119
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#15 of 46 Old 01-13-2007, 03:51 PM - Thread Starter
 
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No confusion here! Your experience is important because not all insurance carriers are the same. I just wanted to put an update since my last post. I saw your post and realized I hadn't done that yet! It remains to be seen what will happen next, but I have all my things ready for a snail mail bombardment if I have to. The thing that stinks about this is that right there in black and white it says exactly what midwifery coverage I have in and out of network.
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#16 of 46 Old 02-15-2007, 07:30 PM - Thread Starter
 
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I received a letter today that said
Quote:
Claim processed according to your benefit plan.
Oh, really? : I wonder how that is when I have midwifery coverage on my policy. 100% in network and a deductible/80% on out of network.

So they are getting a nice, big letter from me and we're calling dh's benefits department tonight.
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#17 of 46 Old 04-02-2007, 09:10 PM - Thread Starter
 
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We ended up calling dh's benefits department and they called the insurance company. UHC admitted it should have been covered and sent it back for prcessing again.

Today I received a check for $1500+!

It's still not the right amount according to my out of network coverage, but I will call tomorrow to get clarification on the amount. I am still going to appeal that it be covered in full because of the lack of in network midwives in my state. But I am very happy that I got this far, even if it took 7 months!
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#18 of 46 Old 04-13-2007, 06:57 PM
 
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Wow! GOod for you! I also have UHC now and you've given me hope that I might get a few dollars coverage out of it - though with our high OON deductible it is still questionable Cigna didn't pay a DIME for my other HB yet happily coughed up more than double the amt for a hospital birth for #1:
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#19 of 46 Old 06-07-2007, 01:55 AM - Thread Starter
 
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I got my official denial of my appeal for the remainder of the midwife's fees the other day. Dh and I are planning another conference call to the benefits department and UHC to have them reconsider. :

The thing is, during our last conference call, they told me that I could have gotten it pre-approved. But they did not offer that during any of my phone conversations with them about midwifery coverage. So I think we have a shot. You can't say "well, you should have...." when I had at least two conversations with them while I was still decided on a care provider.
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#20 of 46 Old 06-15-2007, 11:06 AM
 
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I know I'm a little late posting here, but I am trying to get UHC to cover a home birth (I'm in TX). We JUST found out that we're expecting, and I'd love to get things approved before-hand. I was just wondering if anyone here has experience with getting the birth approved in advance. From what I have read so far, it looks like everyone is just submitting to insurance after the birth.

Anyone have any experience? I have called UHC once and was told they'd only cover a midwife who worked directly for an OB...obviously, as I have found researching online and in this thread, that's not true.
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#21 of 46 Old 06-15-2007, 11:45 AM
 
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I just wanted to update quickly and tell you that after spending some time on the phone with a few UHC representatives, they said that since there are no midwives in-network within 30 miles of me, they can do something called a "gap exception" to get a midwife covered for my home birth. I will find out in 7-10 days what, if anything, is going to be covered. I will let you all know. This information might help another person who has UHC and is trying to get a home birth covered!

Wish me luck!
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#22 of 46 Old 06-16-2007, 11:58 AM
 
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My midwife is the only CNM in the state that does homebirths. She said that because she lives 1.5 hours from me, she will also be billing with the "gap exception" because I am unable to get the services that I require with a midwife anywhere near here (they all only do hospital births w/ OBs).
(I have BCBS)
I will be watching this thread very closely as I am due in 2 weeks (or 4 ) and we have already prepaid my midwife and I am not going down without a fight to get my 70% OON or 80% regular network reimbursement!
Keep us updated gals!

Mama to my own amazing children..student midwife..home birth activist..and gestational surrogate-twin boys weighing 7lbs3oz & 8lbs4oz...vaginal, unmedicated forced induction @ 38w5d
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#23 of 46 Old 06-18-2007, 11:45 AM
 
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This is my first post and hopefully I'm doing it right.
I've been reading this thread with great interest as I'm in the process of trying to get in-network coverage for a twin homebirth from BCBS MA. I've seen other people report also that since BCBS has in-network midwives that they ignore the fact that these in-network midwives either don't provide homebirth, or, in my case, won't treat patients carrying twins. In network my only option is hospital with OB and that just isn't what I'm looking for as long as this pg continues as it has been so far.
I've found an excellent CPM skilled with twins who I adore and am hoping that my arguments will sway BCBS in some way but I know that they may likely continue to blow me off. Their first reply to my request said, in a nutshell, that there are plenty of in-network midwives and I can just use one of them (which I wrote back explaining again that I can't because they won't accept me plus the fact that they are going to save many thousands of dollars by my choice of homebirth over hospital.)
Does anyone have guidance for me on what the Massachusetts or Virginia law is on homebirth coverage? (or where to find it?) or any other ideas or suggestions would certainly be appreciated.
Thanks!!
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#24 of 46 Old 07-30-2007, 03:11 PM
 
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Anyone have any updates on their experiences with BC/BS? I am in Mass and am trying to get my homebirth covered. The rep on the phone said I had to submit an "individual consideration form". Anyone have experience with that?

Mom to DMI & Silly Apple
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#25 of 46 Old 07-30-2007, 04:15 PM
 
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Hmmm, BCBS MA never mentioned an "individual consideration form" to me, could it be plan specific or required by whomever bankrolls your plan? Please share as you find out more, I'm wondering if that's something I need to ask about.

Our BCBS plan seems to only cover CNMs and I am not eligible for their services. CPMs can legally practice here (VA) and I was hoping for a coverage exception since the CNMs who are covered won't take me. So far no dice and no help from hubby's employer who seems totally unwilling to do anything to assist.

But it does rather seem that individual consideration might be needed. Are you working with a CNM or CPM?
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#26 of 46 Old 07-31-2007, 09:29 AM
 
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CNM only deliver in hospitals and technically are the only ones covered on our plan (which is HMO Blue). We are using a CPM as they are the only ones who deliver outside the hospital. They had her "in their system" as in they had heard of her. I'd never heard of this form but we'll see how far it gets me.

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#27 of 46 Old 07-31-2007, 07:25 PM
 
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I wish you good luck...and would love to hear how it goes. I think I'll ask about the form and see what the reps say to me.

My CPM is also already in the BCBS system which I guess makes it less likely that they'll make a mistake and pay. In my area there are CNMs who do homebirth, but they are hogtied by their OB backups in that they aren't allowed to serve twin pregnancies and hence won't care for me. To me it would seem that this is the perfect situation for an exception since HB is something that is covered and my state licenses CPMs. We've got a long way to go on healthcare in this country.

Best wishes to you in your quest.
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#28 of 46 Old 11-22-2007, 01:46 AM
 
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Quote:
Originally Posted by mama2molly View Post
I just wanted to update quickly and tell you that after spending some time on the phone with a few UHC representatives, they said that since there are no midwives in-network within 30 miles of me, they can do something called a "gap exception" to get a midwife covered for my home birth. I will find out in 7-10 days what, if anything, is going to be covered. I will let you all know. This information might help another person who has UHC and is trying to get a home birth covered!

Wish me luck!
Did you have any luck? I too have UHC and would love to know what your experience was. Thanks.
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#29 of 46 Old 01-07-2008, 02:53 PM
 
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I wrote a letter and included a copy of my states law concerning HB coverage and was approved the first time. I kept it to the facts and did not attempt to sway or sell them on the health benefits of HB or midwifery care...what i have noticed with letter writing is that we often spend a lot of time trying to get someone to feel the same way we do, but that just isn't going to happen most of the time and they lose interest in reading your personal stories or "loony crunchy ideas" and send that denial letter instead.

Shortly after getting approved for the coverage, my HBMW was also added to my providers list of In Network Providers...so no one else has to write a letter to have their birth with her in our area!

I will c&p my letter and their response here, but they can also be found on my website www.JulianArts.com

Please feel free to use my letter in any way you would like! Hope it helps!
Justine

Quote:
After discussing my birthing options with my current health care provider, Ms. Jane Doe, CNM of Local Medical Practice, we have decided that a homebirth is the right option for me. I have included a letter of referral from Jane Doe,CNM, which indicates that Ms. Homebirth Midwife CNM, of Homebirth Midwifery Services is able to provide home birthing services.


I would like to begin seeing Ms. HB Midwife right away for my prenatal care. However, under my current insurance plan with HMO Big Shot Insurance, maternity care by Ms. HB Midwife, is not a covered benefit since she is an out-of-network provider. I am writing to request a an exemption to this policy and authorization for full coverage at the In-Network Benefit Level for my prenatal care, homebirth, transfer to hospital if necessary, and postpartum care under the care and supervision of Ms. Homebirth Midwife CNM, of Homebirth Midwifery Services.


Since my current CNM cannot provide these services, I ask you to please consider New York Insurance Law § 4303(c)(1) as it states:


“If an HMO does not have a midwife who assists in home births in its network, it must allow the prospective mother to access such a midwife, so long as that provider meets the minimum requirements of the plan, who is not in the HMO's network.”


Ms. HB Midwife is fully licensed and legally able to provide home birthing services in the state of New York. She has a collaborative agreement with Dr. Nice Guy and Dr. Supportive who are both In-Network Providers under my current insurance plan. These doctors are unable to perform home birthing services themselves, however, they will be available for consultation, collaboration and transfer of care if necessary. I understand that the safest place for induction/augmentation of labor, regional anesthesia in labor, and surgical birth is at a hospital, and if any of these medical interventions becomes necessary, I will be transferred to the hospital.


I sincerely hope that you will grant me coverage at the In-Network Benefit Level in response to this request. I wish to have a well-monitored childbirth that is responsive to my needs and I feel I am best able to obtain that care with a Certified Nurse Midwife who can attend me at my home. I know that HMO Big Shot Insurance is committed to patient needs and providing high-quality, cost-effective care.

For further questions, please feel free to contact Ms. HB Midwife at (xxx) yyy-0000.

Thank you for your consideration,

Justine Julian
Allegany NY


Here is the response I received from HMO Big Shot Insurance dated a mere 2 days later!



December 13, 2007
Dear Ms Julian,
Thank you for your request for home birthing coverage.


We have reviewed the benefit structure and policy coverage of your health insurance coverage. Your request for us to provide coverage of home birthing under your contract is a VALID and REASONABLE service. The claim for services rendered by a licensed practitioner will be adjudicated and processed in accordance with the provisions of your contract.


While we support your decision on home birthing, we would like to make you aware of the following information. There are several issues that are central to question home birthing services.


We are aware that many medical liability insurance carriers will not provide coverage for practitioners when the series is performed at home instead of a medical facility. This is an area you may want to investigate prior to the expected delivery of your child.


We do not examine the credentials of practitioners who provide services to our members who are not participating with us. The quality and experience of the practitioner you select is a personal choice. HMO Big Shot Insurance does not make any claims regarding the quality or experience of practitioners who may perform home birthing.


We asked the physicians who participate in our Credentials Committee to review the issue of home birthing. The Credentials Committee physicians raised several issues. In addition to the above credentialing and liability issues, the physicians were concerned about the care of newborns in a home birthing environment. If a newborn infant requires any special care or emergency treatment, a detailed response plan should be in place at the time of delivery.


Thank you for the opportunity to provide the above details. If you have any questions, please feel free to call XXX-YYY-0000.

Sincerely,
Ms. Almost Supportive, MD
Medical Director of HMO Big Shot Insurance

Justine--Wife to Sir Hubby, HBAC Momma to 5 kiddos including Lazlo born 1/6/10 gently at home!
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#30 of 46 Old 03-23-2008, 06:18 PM
 
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Has anyone had Aetna cover their HB costs?
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