When I first began the appeals process I wrote a separate letter for each individual claim that I was appealing… eight claims in all. Later in the process when it became clear (to me) that BCBSAZ was not going to respond to me with the same courtesy, I began to combine all of of my claim appeals into one letters.
Below you can read some of my appeal letters I have written since September. Writing appeal letters and staying up-to-date on my case has become a part-time job… that I never wanted in the first place! All of the letters listed below were also carbon copied to the Arizona Department of Insurance.
Appeal #1: Related to an OB Triage visit that occurred pre-term when I was 34 weeks pregnant with Lily. Claim total, $3,405.60
September 21, 2009
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by Chandler Regional Hospital for Elizabeth Langford. The charges were rendered on July 7, 2009 and totaled $3,405.60 Blue Cross Blue Shield of Arizona has denied payment for the performed services stating that the services are not a benefit of my benefit plan.
At 34 weeks and two days gestation I began experiencing preterm labor that required medical treatment to stop my contractions and allow my pregnancy to continue in order to protect my health and the health of my fetus.
I referred to Blue Cross Blue Shield’s list of Complications of Pregnancy and Preterm Labor (labor before 37 weeks gestation with documented cervical changes of dilation and/or effacement) requiring medical treatment is listed as a complication of pregnancy. Therefore the costs associated with my OB Triage visit to Chandler Regional Hospital on July 7, 2009 should be the responsibility of Blue Cross Blue Shield of Arizona.
I have included documentation from my OB Triage visit to Chandler Regional Hospital for treatment on July 7, 2009 with this letter. I ask that you reconsider your denial and pay for all of my outstanding claims associated with claim number XXXXXXXXX8900. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Enclosures:
1. Page 34 of the Blue Preferred Copay for Ind 10/08
2. Pages 1-2 of the Blue Cross Blue Shield of Arizona Medical Coverage Guidelines for Complications of Pregnancy.
3. OB Triage documentation from Chandler Regional Hospital
4. Contact information for provider: Chandler Regional Hospital
Appeal #2: OB Triage visit on July 23, 2009 when I was pre-term, 36 weeks pregnant with Lily. Claim total, $2,073.98
September 21, 2009
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by Mercy Gilbert Medical Center for Elizabeth Langford. The charges were rendered on July 23, 2009 and totaled $2,073.98. Blue Cross Blue Shield of Arizona has denied payment for the performed services stating that the services are not a benefit of my benefit plan.
At 36 weeks and four days gestation I began experiencing preterm labor that required medical attention due to extreme pain and preterm uterine contractions. The pregnancy resulted in a medically necessary Cesarean section performed by Dr. Sara J. Giali on August 10, 2009.
I referred to Blue Cross Blue Shield’s list of Complications of Pregnancy and Preterm Labor (labor before 37 weeks gestation with documented cervical changes of dilation and/or effacement) requiring medical treatment is listed as a complication of pregnancy. Therefore the costs associated with my OB Triage visit to Mercy Gilbert Medical Center on July 23, 2009 should be the responsibility of Blue Cross Blue Shield of Arizona.
I have included documentation from my OB Triage visit to Mercy Gilbert Medical Center for treatment on July 23, 2009 with this letter. I ask that you reconsider your denial and pay for all of my outstanding claims associated with claim number XXXXXXXX8100. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Enclosures:
1. Page 34 of the Blue Preferred Copay for Ind 10/08
2. Pages 1-2 of the Blue Cross Blue Shield of Arizona Medical Coverage Guidelines for Complications of Pregnancy.
3. Contact information for provider: Mercy Gilbert Medical Center.
Appeal #3: Related to OB Triage visit on July 24, 2009 when I was 36 weeks pregnant with Lily. Claim total, $1,531.33
September 21, 2009
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by Mercy Gilbert Medical Center for Elizabeth Langford. The charges were rendered on July 24, 2009 and totaled $1,531.33 Blue Cross Blue Shield of Arizona has denied payment for the performed services stating that the services are not a benefit of my benefit plan.
At 36 weeks and five days gestation I began experiencing preterm labor that required medical treatment. The pregnancy resulted in a medically necessary Cesarean section performed by Dr. Sara J. Giali on August 10, 2009.
I referred to Blue Cross Blue Shield’s list of Complications of Pregnancy and Preterm Labor (labor before 37 weeks gestation with documented cervical changes of dilation and/or effacement) requiring medical treatment is listed as a complication of pregnancy. Therefore the costs associated with my OB Triage visit to Mercy Gilbert Medical Center on July 24, 2009 should be the responsibility of Blue Cross Blue Shield of Arizona.
I have included documentation from my OB Triage visit to Mercy Gilbert Medical Center for treatment on July 24, 2009 with this letter. I ask that you reconsider your denial and pay for all of my outstanding claims associated with claim number XXXXXXX8100. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Enclosures:
1. Page 34 of the Blue Preferred Copay for Ind 10/08
2. Pages 1-2 of the Blue Cross Blue Shield of Arizona Medical Coverage Guidelines for Complications of Pregnancy.
3. OB Triage documentation from Mercy Gilbert Medical Center for medical treatment on July 24, 2009.
4. Contact information for provider: Mercy Gilbert M
Appeal #4: Annual Well Woman Exam. Claims total, $341.00. A little more than a month into my pregnancy my OBGYN ordered a pap smear for me. I was overdue to have my annual exam by about one month and she requested that I have a pap smear during my routine OB appointment. BCBSAZ has denied my claim to cover the related lab fees totaling $341.00 because BCBSAZ claims that the pap smear was done as part of my maternity care, and maternity care is not a benefit of my policy. After they denied this claim it became very clear to me that no one was actually reading my medical claims, they were simply denying anything that they received. While this claim is for the smallest amount, it is one of the more “insulting” denials I have received during this process.
September 27, 2009
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by Laboratory Corporation of America for Elizabeth Langford. The charges were rendered on December 31, 2008 and totaled $341.00. Blue Cross Blue Shield of Arizona has denied payment for the performed services stating that the services are not a benefit of my benefit plan.
The charges are related to my annual well woman exam that was performed on December 31, 2008 and the necessary labs that were done in conjunction with that exam. My benefits plan entitles me to one well woman exam per year.
I referred to Blue Cross Blue Shield’s list of Preventative Services and “Routine gynecologic exam including Pap test and other cervical cancer screening test” is listed as a benefit of my benefits plan. Therefore Blue Cross Blue Shield of Arizona should reimburse me minus my co-pay for the $341.00 charged by Laboratory Corporation of America for my Pap test.
I ask that you reconsider your denial and reimburse me the $341.00 that I have already paid out of pocket to Laboratory Corporation of America. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Enclosures:
1. Page 41 of the Blue Preferred Copay for Ind 10/08
Appeal #5: Cesarean Section on August 10, 2009. Claim totals, $17,454.70.
September 21, 2009
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by Mercy Gilbert Medical Center for Elizabeth Langford. The charges were rendered between August 9, 2009 and August 13, 2009 and totaled $17,454.70. Blue Cross Blue Shield of Arizona has denied payment for the performed services stating that the services are not a benefit of my benefit plan.
I referred to my policy booklet and it states that a Cesarean section performed “during labor” for documented, medically necessary indications as defined by InterQual Care Planning Criteria, Procedures Adult (Obstetrics & Gynecology) is considered a complication of pregnancy and therefore the costs associated with the procedure should be covered by Blue Cross Blue Shield of Arizona.
My OBGYN, Dr. Giali performed a medically necessary Cesarean section on August 10, 2009 and I have included the statement of medical necessity with this letter. I hope you will reconsider your denial and pay for all of my outstanding claims associated with this procedure. Please review this letter and reconsider the charges you have previously denied. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Enclosures:
1. Page 34 of the Blue Preferred Copay for Ind 10/08
2. Statement of medical necessity for Cesarean section from Dr. Sara J. Giali.
4. Contact information for providers: Mercy Gilbert Medical Center, Dr. Sara J. Giali – Valley Women for Women