I’m supposed to find out this Thursday if I’ve finally been approved by HBCBS of NJ for a breast reduction that is medically necessary. I’ve been seeing doctors for years to address the pain I am in on a daily basis. But I’m not here to prove to you that this is needed- I’m here to discuss my experience navigating HBCBS of NJ insurance. I’m looking for advice to see if I am on the right track. I’m wondering if you have ever been in this position too.
Being a detective to figure out why my insurance hasn’t approved or received certain documents has literally been a part-time job for me – I put at least 6+ hours/week into correspondence insurance and doctors, sometimes double.
I have been waiting since early August of 2021, when all of the additionally requested paperwork was faxed in, to hear if I’ve been approved or denied.
I’ve been checking the status of my surgery pre-authorization on a weekly basis. Last week we hit the 30-day mark and I still didn’t have an answer.
Because I had been waiting and had no answer, a member services representative escalated my case last week to her manager. She followed up with me that same week and told me I was denied, but couldn’t tell me why, show me a letter, or give me a denial code. She referred me to other departments for those answers.
She gave me the number for the appeals department and Utilization Management (UM). I left a message on the appeals dept line. I got ahold of someone in UM, but they told me I can’t do much without a denial letter or code or reason for the denial. This was all going on last Friday, and it was close to 5, so I figured I’d just try again next week to see if different reps give me different answers or are more helpful – which is usually my experience with my insurance.
Today, I spoke with two people on the phone- one was great, the other wasn’t.
Person from Utilization Management was great. I really hope she is actually able to do what she says she can do, which is escalate my case and get someone to approve or deny this week (she also works in the escalation department- and in my experience, those folks are usually the most informed). She is getting back to me this THURSDAY (!!) with an answer whether I’ve been denied or approved.
Here’s the thing though- she told me that my case was just sitting there and not getting reviewed, and that when it was reviewed, “the wrong person reviewed it” (wtf?). I told her it would be a shame if I wasn’t able to get necessary medical care due to neglect. (Rant that I did not say on the phone: I mean seriously, how much more do I need to micromanage this process? The WRONG person looked at my file and denied me medical care??? Just… the HOOPS I have to jump through, the mental energy, the level of micro managing… all while in pain. It’s just wild. End rant) Utilization Management person also told me that the files I faxed over in early August NEVER got sent to Utilization Management. I told her that I have written confirmation that they did (I have reference numbers that correlate to the chat-in-insurance-app conversation I had where this is stated).
I’m not trying to give anyone a hard time, but how am I supposed to navigate a system like this? Where what representatives tell me is repeatedly inaccurate or completely false, resulting in further delaying my needed medical care?
Person from appeals department told me that the files that my doctors faxed over in early August were never received. That’s basically all we talked about since she had a miserable attitude and it was clear she didn’t want to speak with me. She spoke a million miles a minute when telling me the new fax number I should use – a number that was different than the one given to me by the member services representative back in late July/early August.
Not sure if I should even fax anything to that number the mean appeals person gave me since the UM person is escalating EVERYTHING for review this week- she listed out everything and she has it all.
How do I EVER know if I’m being guided in the right direction here? I guess I don’t and just keep spending 6+ hours a week micromanaging a massive company that doesn’t have its sh!t together.
I WANT TO MAKE CLEAR:
I thanked the heck out of the super helpful representative today, the one from UM.
I also do NOT blame the member services representatives or anyone I speak with on the phone – I have a feeling they’re either poorly trained, reading off a script, or both. I am always kind and patient with them, just as I want them to be with me (even though there are SO many instances where right off the bat they are seriously so rude and curt).
ADDITIONAL CONTEXT:
In order to be approved for this surgery, need 3 different doctors medical notes and records to be reviewed. The person from UM is emailing EVERYTHING to the right person (let’s effing hope) for review. That’s why I don’t feel the need to tell me doctors to re-fax all medical records and office notes to the new fax number given to me today- seems like the person from UM is handling that.
But the thing is, by waiting, assuming that the person from UM really is doing what they need to do… let’s say I’m denied again, and I DO need to re-fax all my stuff to the new fax number – it takes days for this stuff to go through to my insurance, and weeks for them to process, if not longer (usually longer). So should I just message my doctors and have them re fax everything? Just to be safe??
submitted by /u/AccomplishedAcadia59
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I’m supposed to find out this Thursday if I’ve finally been approved by HBCBS of NJ for a breast reduction that is medically necessary. I’ve been seeing doctors for years to address the pain I am in on a daily basis. But I’m not here to prove to you that this is needed- I’m here to discuss my experience navigating HBCBS of NJ insurance. I’m looking for advice to see if I am on the right track. I’m wondering if you have ever been in this position too. Being a detective to figure out why my insurance hasn’t approved or received certain documents has literally been a part-time job for me – I put at least 6+ hours/week into correspondence insurance and doctors, sometimes double. I have been waiting since early August of 2021, when all of the additionally requested paperwork was faxed in, to hear if I’ve been approved or denied. I’ve been checking the status of my surgery pre-authorization on a weekly basis. Last week we hit the 30-day mark and I still didn’t have an answer. Because I had been waiting and had no answer, a member services representative escalated my case last week to her manager. She followed up with me that same week and told me I was denied, but couldn’t tell me why, show me a letter, or give me a denial code. She referred me to other departments for those answers. She gave me the number for the appeals department and Utilization Management (UM). I left a message on the appeals dept line. I got ahold of someone in UM, but they told me I can’t do much without a denial letter or code or reason for the denial. This was all going on last Friday, and it was close to 5, so I figured I’d just try again next week to see if different reps give me different answers or are more helpful – which is usually my experience with my insurance. Today, I spoke with two people on the phone- one was great, the other wasn’t. Person from Utilization Management was great. I really hope she is actually able to do what she says she can do, which is escalate my case and get someone to approve or deny this week (she also works in the escalation department- and in my experience, those folks are usually the most informed). She is getting back to me this THURSDAY (!!) with an answer whether I’ve been denied or approved. Here’s the thing though- she told me that my case was just sitting there and not getting reviewed, and that when it was reviewed, “the wrong person reviewed it” (wtf?). I told her it would be a shame if I wasn’t able to get necessary medical care due to neglect. (Rant that I did not say on the phone: I mean seriously, how much more do I need to micromanage this process? The WRONG person looked at my file and denied me medical care??? Just… the HOOPS I have to jump through, the mental energy, the level of micro managing… all while in pain. It’s just wild. End rant) Utilization Management person also told me that the files I faxed over in early August NEVER got sent to Utilization Management. I told her that I have written confirmation that they did (I have reference numbers that correlate to the chat-in-insurance-app conversation I had where this is stated). I’m not trying to give anyone a hard time, but how am I supposed to navigate a system like this? Where what representatives tell me is repeatedly inaccurate or completely false, resulting in further delaying my needed medical care? Person from appeals department told me that the files that my doctors faxed over in early August were never received. That’s basically all we talked about since she had a miserable attitude and it was clear she didn’t want to speak with me. She spoke a million miles a minute when telling me the new fax number I should use – a number that was different than the one given to me by the member services representative back in late July/early August. Not sure if I should even fax anything to that number the mean appeals person gave me since the UM person is escalating EVERYTHING for review this week- she listed out everything and she has it all. How do I EVER know if I’m being guided in the right direction here? I guess I don’t and just keep spending 6+ hours a week micromanaging a massive company that doesn’t have its sh!t together. I WANT TO MAKE CLEAR: I thanked the heck out of the super helpful representative today, the one from UM. I also do NOT blame the member services representatives or anyone I speak with on the phone – I have a feeling they’re either poorly trained, reading off a script, or both. I am always kind and patient with them, just as I want them to be with me (even though there are SO many instances where right off the bat they are seriously so rude and curt). ADDITIONAL CONTEXT: In order to be approved for this surgery, need 3 different doctors medical notes and records to be reviewed. The person from UM is emailing EVERYTHING to the right person (let’s effing hope) for review. That’s why I don’t feel the need to tell me doctors to re-fax all medical records and office notes to the new fax number given to me today- seems like the person from UM is handling that. But the thing is, by waiting, assuming that the person from UM really is doing what they need to do… let’s say I’m denied again, and I DO need to re-fax all my stuff to the new fax number – it takes days for this stuff to go through to my insurance, and weeks for them to process, if not longer (usually longer). So should I just message my doctors and have them re fax everything? Just to be safe??
submitted by /u/AccomplishedAcadia59 [link] [comments]Read Morer/HealthInsurance