I have Horizon Blue Cross Blue Shield NJ
I need a surgery done, so my surgeon submitted documentation in July. I was denied because insurance claimed they didn’t receive certain information that I know they did. I appealed, and now they’re telling me a few things:
Why I was denied
That I’d need 6 more months of medical documentation that proves that I need this surgery
That I only have 4 months from the 2nd denial date to submit any extra info I want an external Independent Review Organization (IRO) to look at. (But if you read #2, you see that insurance is also telling me I need 6 months of additional medical documentation to be approved for the surgery)
The claims advocate and a member services representative both told me that if I don’t go through with the IRO In 4 months (deadline 2/8/22), I will have to wait a year before I can appeal again (and by that time I’ll have aged out of my parents’ insurance).
BUT when I called the Utilization Management Appeals department, I was told that my surgeon can resubmit a request for pre authorization after the external appeal step is done, assuming I have completed the 6 months of extra doctors appointments or something else to address the reason I was denied (which would take us to May 2022).
Can you help me make sense of this or figure out how to prove the rules? Because I’m being told different things.
submitted by /u/AccomplishedAcadia59
[link] [comments]I have Horizon Blue Cross Blue Shield NJ I need a surgery done, so my surgeon submitted documentation in July. I was denied because insurance claimed they didn’t receive certain information that I know they did. I appealed, and now they’re telling me a few things: Why I was denied That I’d need 6 more months of medical documentation that proves that I need this surgery That I only have 4 months from the 2nd denial date to submit any extra info I want an external Independent Review Organization (IRO) to look at. (But if you read #2, you see that insurance is also telling me I need 6 months of additional medical documentation to be approved for the surgery) The claims advocate and a member services representative both told me that if I don’t go through with the IRO In 4 months (deadline 2/8/22), I will have to wait a year before I can appeal again (and by that time I’ll have aged out of my parents’ insurance). BUT when I called the Utilization Management Appeals department, I was told that my surgeon can resubmit a request for pre authorization after the external appeal step is done, assuming I have completed the 6 months of extra doctors appointments or something else to address the reason I was denied (which would take us to May 2022). Can you help me make sense of this or figure out how to prove the rules? Because I’m being told different things. submitted by /u/AccomplishedAcadia59 [link] [comments]Read Morer/HealthInsurance