Appeal Denied, Help

My three year old daughter had a severe tongue tie impacting her speech and ability to chew. Her pediatrician recommended having it corrected and referred us to an ear nose and throat doctor. Prior to the procedure, someone from the hospital called me and told me the costs for the facility fee, she said our insurance, Blue Cross Blue Shield, was covering 85% so after my $500 deductible I would need to pay the remaining 15% coinsurance on the day of the procedure. Our insurance processed/approved the facility claim and we paid our part the morning of the surgery. After the surgery, we received bills for her anesthesia and physician fee because our insurance denied those two claims. I called Accolade which deals with the billing and claims for Blue Cross. Apparently our plan does not cover tongue tie surgeries, saying this should be covered by dental, and they are refusing to cover the second two claims. They said the facility claim they approved was done so in mistake and I should just be happy to have that part covered. I did an appeal and said that if the facility fee was not mistakenly covered the week before the procedure, I would have never followed through with it and would have gone through an oral surgeon through our dental insurance (which I found out would have been covered at 100% after the fact). I had no idea a procedure like this wouldn’t be covered because it was a medical issue and she was so young she hadn’t even seen a dentist yet. Also, the fact that our medical insurance covered the first portion led me to believe it was a covered service. I’m planning on doing a second level appeal but need advice on how to proceed since my first appeal was denied.

submitted by /u/Cap10kel
[link] [comments]My three year old daughter had a severe tongue tie impacting her speech and ability to chew. Her pediatrician recommended having it corrected and referred us to an ear nose and throat doctor. Prior to the procedure, someone from the hospital called me and told me the costs for the facility fee, she said our insurance, Blue Cross Blue Shield, was covering 85% so after my $500 deductible I would need to pay the remaining 15% coinsurance on the day of the procedure. Our insurance processed/approved the facility claim and we paid our part the morning of the surgery. After the surgery, we received bills for her anesthesia and physician fee because our insurance denied those two claims. I called Accolade which deals with the billing and claims for Blue Cross. Apparently our plan does not cover tongue tie surgeries, saying this should be covered by dental, and they are refusing to cover the second two claims. They said the facility claim they approved was done so in mistake and I should just be happy to have that part covered. I did an appeal and said that if the facility fee was not mistakenly covered the week before the procedure, I would have never followed through with it and would have gone through an oral surgeon through our dental insurance (which I found out would have been covered at 100% after the fact). I had no idea a procedure like this wouldn’t be covered because it was a medical issue and she was so young she hadn’t even seen a dentist yet. Also, the fact that our medical insurance covered the first portion led me to believe it was a covered service. I’m planning on doing a second level appeal but need advice on how to proceed since my first appeal was denied. submitted by /u/Cap10kel [link] [comments]Read Morer/HealthInsurance

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