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Appealing the Insurance Company?? HOW lol??!!!

Apr 29, 2011 - 4 comments

Back in March 2011, I had some extensive surgery done including a Supracervical Hysterectomy, Appendectomy, Excision of Endometriosis and Lysis of Adhesions. I knew upfront that the Surgeon who is an Endo Specialist is out of network for all insurance companies ( I guess most are...). Anyways, Has anyone ever done the appeal process to get your claims paid as in network? How do I go about this to get the best results? Thanks!!!

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1396867 tn?1520810258
by hopeitworks, Apr 29, 2011
What type of plan do you have with your insurance? If you have both inn and oon benefits, it maybe harder to get it approved. I would suggest you see if there are any endo specialists in your area(who are in network). If not be sure to include that in your appeal. Basically you want to point out that there were no other providers who are in network who could render the service/.care you needed. Also you want to be sure you havent missed the appeal deadline. You have anywhere from 30-60 days from the date of the explantion of benefits in most cases.

Let me know if you have any other questions(I work for a health insurance company)

Good Luck!!

478429 tn?1265244387
by dnikki0928, Apr 29, 2011
Thanks! All endo specialists aren't even in my state lol!!! We have military insurance so it's a little different than regular. Basically we can see whoever we want as long as they accept Tricare. The specialist accepts all insurance, they just don't have a contract with any companies - know what I'm saying? I guess I'll start my appeal letter this weekend....Geesh lol

1396867 tn?1520810258
by hopeitworks, Apr 30, 2011
Yes I so anyone can accept the insurance they just get paid at the non network rate. If there is no one in your state who is part of yourplan. I dont know military insurance. But Id think you have a pretty good chance. Good Luck!!

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by sweetpea03, May 09, 2011
Have the endo specialist write a letter to your insurance company stating that you needed this procedure done and you will also write a letter to the insurance company explaining that you needed these procedures done and this specialist was the only one who was qualified to do it. I've had to appeal my insurance company MANY times, so I have gotten to be a pro at writing these letters. Just make sure that they know that this is the only doctor who was capable of doing this procedure for you. Good luck with it!

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