What help, information & resources can you suggest to help me file an

appeal or grievance with an Insurance Company?

The process of appeals & grievances gets very technical, legal, etc.  I won’t even attempt to summarize it here.  Please follow the links below, guides & summaries to the right,  check your policy – evidence of coverage and check the law.

Medical Procedures?

Was your procedure Medically  Necessary?

Independent Medical Review

Blue Cross Clinical UM (Utilization Management) Guidelines,

Did you use the Correct MD or hospital – Provider List and

Did you Review the procedures in your actual policy, evidence of coverage?

Here’s a sample Speciment EOC Evidence of Coverage – Platinum Plan Page 151

Reasons why the Claim might be denied

Did you tell the truth on your application?
How does the Insurance Company know, if the application wasn’t filled out correctly?
Here’s where they write to your MD, before a claim is even turned in.

How about doing a pros & cons spreadsheet – Ben Franklin method?  It’s important to know the other sides point of view and potential arguments & evidence. 

Billing Codes – Satire or how it really works?

Was the policy in force?  Lapse non pay?

Insurance Company & Regulatory Agency Grievance Procedures & Forms

Check your EOC – Evidence of Coverage for procedures & where to get forms.

Kaiser, & Blue Shield Grievance Forms

Aetna

Blue Cross Grievance Procedures

Notice

Blue Shield – General Info.  Appeals & Grievances  PO Box 629007  El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585

CA Department of Insurance  

IMR – Independent Medical Review  

REQUEST FOR REVIEW OF CANCELLATION, RECISSION, OR NONRENEWAL OF HEALTH CARE SERVICE PLAN BENEFITS

   

Consumer Links & Resources

How to gather documents to prove your case – Small Claims Manual

Prove you never got a letter?

How to tell your story, timeline and background – actual attorney brief to the court.

How to create a TIMELINE in Word, Excel, PowerPoint

Health Net faces suit over refusal to cover treatments LA Times 9.13.2012

Appeal Guide – Washington State Department of Insurance 62 pages pdf

Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$

Find an Attorney

Health Consumer Alliance HCA
Part of Department of Managed Health Care

What is HCA?

Patient Advocate.org

Health Plus Advocates

Health Consumer Alliance

Center for Health Care Rights 

National Association of Health Care Advocacy

California Health Consumer Advocacy Coalition

CA Health Care Advocates 

HICAP

 

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy #EOC with Definitions
Specimen Policy with Definitions

Steve Explains how to read EOC

#Appeal Guide 
DOI Washington State

how to appeal health care insurance decesion

*************************

Navigating the Appeals Process -

Patient Advocate Foundation 

Navigating the Appeals Process

 

Kantor & Kantor Attorneys

Right to Appeal - if claim denied

You Tube Videos

 

CA #SmallClaims Court Guide 56 Pages
Gathering the documents you need
CA Small Claims Court Guide

 

Department of Consumer Affairs - Mediation Request ONLINE

mediation request

How Mediation Works & Paper Mediation Request Form

 

Appeals?  Grievances?

Check the FULL policy, EOC - Evidence of Coverage here's a specimen and see what the rules are on cancellation and notice.

Then if you do decide to do an appeal, (page 151 in specimen policy) or view our webpage  on appeals, you'll  know what to argue about.

Guide to #Contract Interpretation 

  • Read the Statute – Policy
  • Read the Statute – Policy
  • Read the Statute – Policy
  • Then when you think you understand it, read it again

guide to contract interpretation

Our webpage on

#Reasons for filing a Covered CA appeal

Your eligibility notice explains what you are eligible for and the programs for which you do not qualify. Depending on your eligibility results, you may appeal any of the following (check as many boxes as you would like):

  • I was denied enrollment into a Covered California health plan
  • The amount of Premium Assistance (tax credits that help pay my monthly premium) is not correct – Get Calculation
  • The level of Cost Sharing Reduction (help paying my out of pocket expenses) is not correct
  • I was denied eligibility for an exemption from the individual responsibility CA Mandate Penalty
  • Covered California did not process my information in a timely manner
  • Covered California stated that I am not a US Citizen or US National or a lawfully present individual living in the United States
  • Covered California stated that my application was incomplete
  • I do not have other health coverage (such as free Medi-Cal or employer sponsored insurance) that prevents me from qualifying for insurance through Covered California
  • Covered California stated that I am not a California Resident
  • Covered California stated that I did not pay my premiums by my due date
  • Covered California stated that my MAGI income is too low chart to qualify for Covered California coverage  Get Calculation
    Other Tell us more about why you disagree with Covered California’s decision. You may attach additional sheets of paper if you need more space to write.  Covered CA Appeals Request Form *

We STRONGLY suggest you attach additional sheets of paper and explain your case, with citations, evidence & exhibits.   Be sure to read all the helpful aids we have on this page.  You are going up against well versed opponents!

We are not attorneys and can just point out the law, rules, relevant sections in the EOC Evidence of Coverage.

Check out the forms and Appeals Procedure on Covered CA’s Website , the materials below and to the right, our main page on Appeal & Grievances?  and the child & sibling pages.

We also need you to write out your story and including all the proofs – evidence & exhibits.

See also our main page on appeals, namely how to gather your evidence and exhibits.   Here’s an example of a decision from the Administrative Law Judge for Covered CA.

We might be able to help you file and process your  appeal  (click for form)  , IF you appoint us (Steve Shorr) as your Certified Insurance Agent, by  following these instructions as we are paid a measly monthly sum  by Covered CA to help you.

#Attorney  's that can help you through the Social Security Disability maze

We don't necessarily know these attorney's...

Covered CA Appeals Decision #Polk Case

Polk Case Covered CA Appeal

Sample Letter for Appeal

Explanation on Insure Me Kevin . com - Polk Case

Check out where administrative law judge said he wished he could make Covered CA pay the costs of their bogus advise but didn't have that authority click to scroll down - view more commentary Polk Case.

Covered CA Polk Case

Q & A on our Website

 

How to file #Medicare appeals, deal with issues, claims, problems, etc.

Please review the brochures, information and links below and on your right.  Appeals are a complex subject and on this page, we are giving you mostly official guides and not our summary or essays.

Medicare Complaint Form on Medicare.Gov

How to file a complaint – Medicare.Gov

Medicare Appeals Publication # 11525 60 pages

Rights & Appeals for Part D Rx – Guide to Rx # 11109

Medicare Rights & Protections  Publication 11534

File complaint against Medicare itself?

Medicare Contact Info  *  More  *  Forms  *

HICAP CA  * Rest of USA *  (Health Insurance Counseling and Advocacy Program) provides free, confidential one-on-one counseling, education, and assistance to individuals and their families on Medicare, Long-Term Care insurance, other health insurance related issues, and planning ahead for Long-Term Care needs. HICAP also provides legal assistance or legal referrals in dealing with Medicare or Long-Term Care insurance related issues.

HICAP counselors are trained in Medi-Cal and Medicare and can help you understand the complex insurance options to find the best fit for you. You can also learn about Medicare or Medi-Cal by attending community presentations or conferences conducted by HICAP counselors.  Medicare & You – see link in side panel

***Sure they might be of help, but how much training, licensing, malpractice coverage  and experience do licensed agents have.  Look at all the information on this site!

Sample Evidence of Coverage

Medicare ​#Appeals  11525

Medicare Appeals

 

you tube videos

 Filing an appeal with Medicare

#Medi-Cal Appeal & Hearing Rights

Health Care Services and Benefits

You have the right to ask for an appeal if you disagree with the denial of a health care service or benefit.

If you are in a Medi-Cal managed care plan and you get a Notice of Action letter telling you that a health care service or benefit is denied, you have the right to ask for an appeal.

You must file an appeal with your plan within 60 days of the date on the Notice of Action. After you file your appeal, the plan will send you a decision within 30 days. If you do not get a decision within 30 days or are not happy with the plan’s decision, you can then ask for a State Fair Hearing. A judge will review your case.  You must first file an appeal with your plan before you can ask for a State Fair Hearing. You must ask for a State Fair Hearing within 120 days of the date of the plan’s written appeal decision.

If you are in Fee-for-Service Medi-Cal and you get a Notice of Action letter telling you that a health service or benefit has been denied, you have the right to ask for a State Fair Hearing right away. You must ask for a State Fair Hearing within 90 days of the date on the Notice of Action.

You also have the right to ask for a State Fair Hearing if you disagree with what is happening with your Medi-Cal application or eligibility. This can be when:

• You do not agree with a county or State action on your Medi-Cal application
• The county does not give you a decision about your Medi-Cal application within 45 or 90 days
• Your Medi-Cal eligibility or Share of Cost changes Eligibility Decisions

If you get a Notice of Action letter telling you about an eligibility decision that you disagree with, you can talk to your county eligibility worker and/or ask for a State Fair Hearing. If you cannot solve your disagreement through the county, you must request a State Fair
Hearing within 90 days of the date on the Notice of Action. You can ask for a State Fair Hearing by contacting your local county office. You can also call or write to:

California Department of Social Services
Public Inquiry and Response
PO Box 944243, M.S. 9-17-37
Sacramento, CA 94244-2430
1-800-743-8525, (TTY 1-800-952-8349)

You can also file a hearing request online at:

cdss.ca.gov/hearing-requests 

If you believe you have been unlawfully discriminated against on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can make a complaint to the DHCS Office of Civil Rights.

You can learn how to make a discrimination complaint in “Federally Required Notice Informing Individuals About Nondiscrimination and Accessibility Requirements” on page 21.

About State Fair Hearings

The State will tell you it got your hearing request. You will get a notice of the time, date and place of your hearing. A hearing representative will review your case and try to resolve your issue. If the county/State offers you an agreement to solve your issue, you will get it in writing.

You can give permission in writing for a friend, family member or advocate to help you at the hearing. If you cannot fully solve your issue with the county or State, you or your representative must attend the State Fair Hearing. Your hearing can be in person or by phone. A judge who does not work for the county or Medi-Cal program will hear your case.

You have the right to free language help. List your language on your hearing request. Or tell the hearing representative you would like a free interpreter. You cannot use family or friends to interpret for you at the hearing.

If you have a disability and need reasonable accommodations to fully take part in the Fair Hearing process, you may call 1-800-743-8525 (TTY 1-800-952-8349).

You can also send an email to To get help with your hearing, you can ask for a legal aid referral. You may get free legal help at your local
legal aid or welfare rights office MyMedi-Cal Pamphlet *

#My Medi-Cal
How to get the Health Care You Need
24 pages

Smart Phones - try turning sideways to view pdf better
My medi cal explanation of medi cal

Western Poverty Law - Insurance for Low Income

Advocate Guide to Medi Cal 

advocate guide to Medi Cal

Nolo Social Security, Medicare, Medi Cal & Government Pensions

nolo social security government pensions

Our Webpage on

COVID 19

symptoms of corona virus

Claim Splitting – #Res Judicata
you can’t just sue someone two or more times to get around the small claims court limit.

Laws Against
Claim Splitting – Preclusion – Res Judicata

  1. Rule:
    1. If judgment is rendered in favor of a plaintiff in a particular suit, the plaintiff is precluded from raising claims (in any future litigation) which were raised in (or could have been raised) in that lawsuit.
  2. Elements:
    1. Before a court will apply the doctrine of res judicata to a claim,three elements must be satisfied:
      1. There must have been prior litigation in which identical claims were raised (or could have been raised). In general, claims are sufficiently identical if they are found to share a “common nucleus of operative fact.”
    2. scope:
    3. Res judicata bars relitigation of claims that were previously litigated as well as claims that could have been litigated in the first lawsuit. sparknotes.com   lectlaw   caught.net

If your claim is over the small claims monetary limit,you may file a case in the regular superior court,where you can either represent yourself or hire an attorney to  represent you. Instead of doing that,you may choose to reduce the amount of your claim and waive(give up) the rest of the claim in order to stay within the small claims court’s monetary limit on claims. Before reducing your claim, discuss your plans with a small claims adviser or an attorney. Once the dispute is heard and decided by the small claims court, your right to collect the amount that you waive will be lost forever.

.

Definition – Claim Splitting lectlaw.com Dividing a single or indivisible claim or cause of action into separate parts and bringing separate suits upon it, either in the same court , or in separate courts or jurisdictions.

Small Claims Adviser Los Angeles 213.974.9759

Information for Plaintiff SC 100

Allstate v Rapton – waiver of damages over $5k limit, res judicata

 

Res Judicata

You cannot divide a claim into 2 or more claims (called claim splitting) just to avoid the limit…..Or, lower the amount you ask for and give up (or waive) the rest. That way you can keep your claim in Small Claims court.
.occourts.org

fees charged by the attorney for private assistance are not recoverable as court costs or damages(dca.ca.gov)

 

Small Claims Procedures & Practices
§6.14 Res Judicata 

Under the doctrine of res judicata, a small claims court judgment is a bar to a second suit on the same cause of action. [Pitzen v Superior ; Allstate Ins. Co. v Mel Rapton, Inc. (2000) 77 CA4th 901, 905.]

A small claims judgment for a plaintiff, however, is not given collateral estoppel issue-preclusion effect on other actions against the defendant. It would be unfair to have plaintiff’s choice of small claims court bind the defendant when the record does not fully reflect the issues raised and decided there. [Sanderson v Niemann]

But a defendant may raise collateral estoppel issue preclusion if the defendant prevailed in a previous small claims action. There is no rationale for refusing to afford collateral estoppel effect to issues litigated and decided against a plaintiff. Fundamental fairness dictates that a plaintiff who chose to litigate in small claims court cannot cite the informality of that forum to gain a second chance to litigate a decided issue. Relitigating decided issues is also inconsistent with the public policy that a small claims plaintiff is bound by an adverse judgment. [Bailey v BrewerPitzen v Superior Court] §6.14 Res Judicata 

If you do try to unlawfully collect a debt by claim splitting – you might get busted under Fair Debt Collection Laws!

You Tube Video’s on Res Judicata (Double Jeopardy)

Enforcement

Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –   CA Healthline 5.3.2016

WOW!!! 2.8 Million June 2019 CA Managed Health Care * Insure Me Kevin.com  * 

Dealing with Customer Service Issues

  • First and foremost, be polite. These are crazy days as well for service reps, nearly all of whom aren’t to blame for their companies’ penny-pinching practices. A little civility goes a long way.
  • Don’t be shy about escalating. Front-line service reps are frequently not given the power to resolve matters on their own and will often give an unsatisfactory response. Ask to speak with a supervisor.
  • If that doesn’t work, write to the company’s chief executive or president, detailing the nature of the problem and providing as much documentation as possible. Most big companies have special dispute-resolution departments at senior levels.
  • Be persistent. If it becomes clear that you’re not going away, some companies will finally throw in the towel and offer the response you’re seeking. Squeaky wheels and all that. LA Times 8.8.2020 *

Milliman Waste Study

The U.S. healthcare system wastes close to three-quarters of a trillion dollars a year—and the implications are not just financial. Many of the tests, treatments, and procedures that comprise healthcare waste can expose patients to undue physical, emotional, or financial harm.  http://www.milliman.com/waste

Top 10 Wasteful Services

10 wasteful procedures health

 

SNAFU - Situation Normal - All Fouled Up
snafu

I learned the word SNAFU  Situation Normal, All Fouled Up  in the dorm, when I attended San Diego State in the early 70's and earned a degree in Insurance.  In all that time, I've never been able to use the word in a sentence, until last 10.1.2013, when Covered CA.com, Health Care.Gov nor the Insurance Company Websites or my own Quote Engine that I pay around $250/month for were supposed to launch, but did not do it properly.

Steve - when he's not updating the website outside of Open Enrollment
Steve - when he's not updating the website outside of Open Enrollment

1989 Maytag Repairman Christmas Commercial
Maytag Commercial

What is the #unauthorized practice of law?

 

California broadly defines the “practice of law” as dispensing legal advice or service, even if the advice or service does not relate to any matter pending before a court. * Legal Advice vs Legal Information * Shouse Law *    (Mickel v. Murphy (1957) 147 Cal.App.2d 718, 721.)    

Advising boards on how the statutes pertain to them or what actions would violate the law or the governing documents. * Supreme Court opinion. *

1.  Advising boards about rights, duties and liabilities. That includes but is not limited to:

  • Interpreting the Davis-Stirling Act,
  • Interpretation of contract provisions,
  • Disputed maintenance and repair issues,
  • Settlement issues.

2. Preparing documents that alter rights, duties and liabilities. Managers and management companies can prepare documents that are incidental to the regular course of their business. Anything beyond that must be prepared by legal counsel. That includes but is not limited to:

  • Amendments to CC&Rs, Bylaws, and Articles of Incorporation,
  • Contracts and contract provisions,
  • Election rules,
  • Rules enforcement policies,
  • Settlement agreements, and Davis Stirling.com *

 

What is “Advice?”

1ato give (someone) a recommendation about what should be doneto give advice to Her doctor advised her to try a drier climate.
 
bCAUTIONWARN advise them of the consequences
cRECOMMEND advise prudence
 
2to give information or notice to INFORM  advise them of their rights

intransitive verb

1to give a recommendation about what should be doneadvise on legal matters
2to talk with someone in order to decide what should be done CONSULT advise with friends  Webster * CA Courts * 
 
What if it’s just Information?
 
See the CA Courts treatise on this.
 

Violation of the BJR.
Business Judgment Rule

The hourly rates for HOA lawyers typically range from $175 to $350, whereas legal advice from a manager is free. It is understandable that boards would try to save money by seeking free legal counsel from their managers. However, doing so exposes directors to significant risk. By statute, directors are protected from personal liability for errors in judgment if they follow the Business Judgment Rule, which requires that decisions by directors be:

  1. In good faith,
  2. In a manner which the director believes to be in the best interests of the corporation, and
  3. With such care, including reasonable inquiry, as an ordinarily prudent person in a like position would use under similar circumstances. (Corp. Code §7231(c).)

If a board relies on legal counsel from a manager and things go awry, directors will have difficulty convincing a jury that seeking legal advice from a manager was prudent.     Davis Stirling.com Los Angeles County Bar Assoc. – lacba.org

Legal Document Assistant

It is unlawful for any person engaged in the business or acting in the capacity of a legal document assistant or unlawful detainer assistant to do any of the following:

(d) Provide assistance or advice which constitutes the unlawful practice of law pursuant to Section 6125, 6126, or 6127.

(e) Engage in the unauthorized practice of law, including, but not limited to, giving any kind of advice, explanation, opinion, or recommendation to a consumer about possible legal rights, remedies, defenses, options, selection of forms, or strategies.  §6411 *

 Unlawful Practice of Law [6125 – 6133]
Legal advice refers to the written or oral counsel about a legal matter that would affect the rights and responsibilities of the person receiving the advice. In addition, actual legal advice requires careful analysis of the law as it applies to a person’s specific situation – as opposed to speculation based on generic facts. From a legal standpoint, the giving of legal advice is tantamount to the practice of law, In a nutshell, legal advice has the following characteristics:

  • Requires legal knowledge, skill, education and judgment
  • Applies specific law to a particular set of circumstances
  • Affects someone’s legal rights or responsibilities
  • Creates rights and responsibilities in the advice-giver

Unlike legal information – such as information posted on a street sign – legal advice proposes a specific course of action a client should take. For instance, it’s the difference between telling someone what to do (legal advice) as opposed to how to do it (legal information). Examples:

  • Selecting, drafting, or completing legal documents or agreements that affect the legal rights of a person
  • Negotiating legal rights or responsibilities on behalf of a person
  • Speculating an outcome
  • Selecting or filling out specific forms on behalf of a client

 

Links & Resources

Technical Stuff for Attorneys

Medicare Technical & Research Links

Medicare Claims Processing Manual Technical 319 Pages

One hour webinar by an attorney, on how to do claims & appeals – You Tube

42 CFR Part 422, Subpart M – Grievances, Organization Determinations and Appeals

Medicare Claim Processing Manual

medicare.claim.processing.manual

Advocates Guide to Surprise Medical Bills

Advocates guide to surpize medical bills

 

 

From CMS Site

 

Technical Links – Appeals & Grievances

Page 19 Section §2719 of Health Care Reform -Appeals Process

45 CFR Part 147    Interim Final Rules for Group Health Plans and Health Insurance Issuers – Appeals

§ 147.136 — Internal claims and appeals and external review processes.

7/26/2011 – Final Rules – EBSA – Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction [PDF]

More Final Rules for EBSA

§10123.13. (a) Every insurer…shall reimburse claims …, whether in state or out of state, … as soon as practical, but no later than 30 working days after receipt…

(b) If an uncontested claim is not reimbursed … within 30 working days…interest shall accrue and shall be payable at the rate of 10 percent per annum …

Search & Find CPT Current Procedural Terminology codes and their relative values at CPT Code/Value Search – Medicare Billing Codes This is a free site for patients and consumers.

See also Medical Necessity

California Insurance Code  §790.03 (h) Knowingly committing or performing with such frequency as to indicate a general business practice any of the following unfair claims settlement practices:   Calif. Code of Regulations TITLE 10. CHAPTER 5 ADOPT SUBCHAPTER 7.5 with new 2004 amendments on CA Department of Insurance Site

33 comments on “Appeal & Grievances? Medicare – Medi Cal – Covered CA

  1. Yeah!!!! You did it!!! I’m so thankful!!!

    You are not superman but SuperSteve!!!!!

    You have done the impossible!!!

    I know I know, I shouldn’t be celebrating until I get the insurance. Even coming this far was impossible for me. Without your help, I would have just accept their decision and gone without insurance for a year. I either would have used our savings to pay for surgery or have to wait until next year while suffer the consequences.

    I couldn’t thank you enough. I’m so grateful to you.

  2. If I lost a small claims court lawsuit against a auto repair shop, can I still file a lawsuit against the mechanics?

    I filed a small claims lawsuit against a auto shop for the cost I paid for a procedure I was not happy with. I lost my lawsuit because the commissioner said before he even heard the case, that he knew nothing about auto repairs and unless I had brought an expert witness, which I did not, he was going to rule against me.

    My question is, can I file another lawsuit for the same thing ( repair bills) against the mechanics who performed the bad repair. Even though they have their own licenses they are actual employees of the shop. And they did come to court to testify for the shop in the lawsuit I lost.

    would this be considered res judicata?

    • 1st off, I can’t give you legal advise. You are not asking Insurance Advise. I’ll see if I can point to something in the law or the guides for you.

      Did the Judge say dismissed with or without prejudice? That is, did he say you could come back to court with an expert witness. I presume not, from your question, the case was dismissed with prejudice, meaning you can’t bring the case up again – like double jeopardy in a criminal trial.

      The general rule is that a plaintiff who has prosecuted one action against a defendant and obtained a valid final judgment is barred by res judicata from prosecuting another action against the same defendant Upcounsel.com

      The mechanics didn’t bill you, the shop did. So, wouldn’t that be the same thing? You’re still suing on the exact same invoice.

      I’m sorry, I don’t find a black & white reference for you. See all the information on Small Claims on this website and

      Try calling the Small Claims Advisor in your area Los Angeles 213.974.9759

  3. 11 comments on “Covered CA Appeals”

    1. Anonymous says:

      Are Covered CA administrative law decisions private or a matter of public record?

      Reply
        • In the Decision in the upper right from Covered CA Appeals, it says its protected by WIC 10850

          So, it looks like if it were published, they would have to take your name off. Please check with competent legal counsel. We cannot give legal advise.

          Reply
    2. Anonymous says:

      I made a mistake and took my child off the coverage as she was out of state to go to college. She’s in the ER, what can I do?

      Reply
  4. 52 comments on “Appeals & Grievances Medicare”

    1. Anonymous says:

      How do I file an appeal with Blue Shield dental?

      Reply
    2. Anonymous says:

      I filed an appeal several months ago. No one has contacted me.

      If they deny my appeal, how soon should I know?

      I had a vertical sleeve gastrectomy in October.

      Medicare denied my nutrition appointments which are required. Each one was over $350.

      I was told on the website that Medicare would cover nutrition appointments related to weight loss surgery.

      Please advise.

      Reply
      • What kind of an appeal did you file?

        Do or did you have diabetes, have or been on dialysis or kidney disease?

        IMHO you really need to have your doctor or nutritionist file the appeal or rebill it with the “proper” codes.

        Please note, that I’m NOT your broker or an attorney.

        You’ll generally get a decision from the MAC (either in a letter or an MSN) within 60 days after they get your request. – Please read the entire Medicare Appeals Guide # 11525 Above

        Do you have a Medicare Advantage Plan, Original Medicare or Original Medicare with a Medi Gap Plan?

        Please don’t say “the website” tell me the exact URL – Internet Address

        https://www.medicare.gov/coverage/bariatric-surgery

        Medicare Part B (Medical Insurance) may cover medical nutrition therapy (MNT) services and certain related services if you have diabetes or kidney disease, or you’ve had a kidney transplant in the last 36 months Medicare.Gov 5 pages of detail

        80 page guide for providers to get reimbursed

        Reply
    3. Question

      With all your experience, is there any effective [grievance] agency for me to go to with the HMO Medicare advantage plan [UHC – AARP] I have?

      One of UCLA, Endocrinologists made a huge medication error, from which I am very ill.  UCLA has denied me a second opinion or a higher level of care.

      Answer

      ***One of the very best places to view your rights and procedures for claim problems, appeals, grievances is in the full EOC – Evidence of Coverage  that you have a right to view before purchasing or when you get it in the enrollment paperwork or shortly thereafter.  Get your  EOC go to Table of Contents – Then look for Appeals, claims procedures, etc. and of course the explanation of benefits and if your issue is actually covered.

      Maybe you have a medical malpractice claim? https://www.nolo.com/legal-encyclopedia/medical-malpractice-basics-29855.html

      Reply
    4. See our page on medical necessity.

      What extensive research do you have that Cortisone isn’t the thing to try first?

      Where do you find that Medicare requires cortisone first?

      • Check this instructional bulletin for your doctor

        DOCUMENT MEDICAL NECESSITY TO AVOID DENIAL OF CLAIMS

        CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments. To avoid denial of claims for major joint replacement surgery, the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings. Both physicians and hospitals are responsible for ensuring a complete and accurate record.

        joint replacement

        Joint Replacement Model extended for 3 years

      • Unnecessary health care (overutilization, overuse, or overtreatment) is health care provided with a higher volume or cost than is appropriate.[1] In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending ($750 billion out of $2.6 trillion) in 2012.[2]

        Factors that drive overuse include paying health professionals more to do more (fee-for-service), defensive medicine to protect against litigiousness, and insulation from price sensitivity in instances where the consumer is not the payer—the patient receives goods and services but insurance pays for them (whether public insurance, private, or both).[3] Such factors leave many actors in the system (doctors, patients, pharmaceutical companies, device manufacturers) with inadequate incentive to restrain health care prices or overuse.[1][4] This drives payers, such as national health insurance systems or the U.S. Centers for Medicare and Medicaid Services, to focus on medical necessity as a condition for payment. However, the threshold between necessity and lack thereof can often be subjective.

        Overtreatment, in the strict sense, may refer to unnecessary medical interventions, including treatment of a self-limited condition (overdiagnosis) or to extensive treatment for a condition that requires only limited treatment.

        It is economically linked with overmedicalization. https://en.wikipedia.org/wiki/Unnecessary_health_care

        Reply
      • This looks like the clinical bulletin for Medicare

        The most common reason for total knee replacement surgery is arthritis of the knee joint. Types of arthritis include
        osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). This arthritis
        causes a severe limitation in the activities of daily living, including difficulty with walking, squatting, and climbing
        stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for
        a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of
        pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement
        with other conservative therapies such as steroid injections and physical therapy. Osteonecrosis and malignancy are
        additional reasons to proceed with total knee replacement surgery. The goal of total knee replacement surgery is to
        relieve pain and improve or increase patient function.

        Total knee replacement surgery will be considered medically necessary when one or more of the following criteria are met:

        Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following:

        anti inflammatory medications,

        analgesics,

        flexibility and muscle strengthening exercises,

        supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care],

        activity restrictions as is reasonable,

        assistive device use,

        weight reduction as appropriate, therapeutic injections into the knee as appropriate.

        Documentation Requirements

        The medical record must contain documentation that fully supports the medical necessity and justification of the
        procedure performed.

        https://www.cgsmedicare.com/parta/pubs/news/2015/0415/cope29098a.html

        Reply
      • susan says:

        Here are just 5 of MANY recent reports from the medical community showing that Cortisone DOES NOT FIX MY KNEE–it only masks pain and may cause damage!

        *Harvard Medical School, Cortisone Report, Apr. 1, 2019

        *WebMD, “Disadvantages of Cortisone Injections.”

        *”Cortisone Injection Risks and Side Effects,” Emmanuel Konstantakos, MD Peer Reviewed, 2016, Arthritis Health

        *Dr. McAlindon. “We now know that these injections bring no long-term benefit, and may, in fact, do more harm than good by accelerating damage to the cartilage.”
        This study was supported by the NIH’s NIAMS (R01-AR051361) and National Center for Advancing Translational Sciences

        *Repeated corticosteroid injections to the joint may speed cartilage degeneration.
        Credit Timothy E. McAlindon, M.D., M.P.H., of Tufts Medical Center, Boston.

        Reply
        • Please send the actual links… We are not getting compensated to help you. Please don’t make us spend an hour to find these papers. I did not see ANY requirement in the clinical bulletin or the Major Joint Replacement booklet requiring cortisone.

          What complications might there be from knee replacement?

          Reply
    5. susan says:

      Since my orthopedic surgeon has indicated that I need Total Knee Replacement, how can I over-ride the Medicare requirement that I have Cortisone Injections before I can have the surgery?

      All my extensive research shows that Cortisone is very damaging to skin, bones and surrounding tissue, just prolongs the damage to my knee, and means that I will be that much older perhaps necessitating a longer recovery.

      I am also an athlete and I am unable to participate in my numerous sports so waiting for Total Knee Replacement means it will be much harder to re-gain my fitness.

      Cortisone Injections are just another cost for Medicare (and me) when TKR will be the end result!

      Reply
        • susan says:

          I don’t have a grievance yet–so will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!

          Reply
          • We need to use the exact proper terms.

            Grievance—A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.

            Appeal—An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
            ■ Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
            ■ Your request for payment for a health care service, supply, item, or prescription drug you already got
            ■ Your request to change the amount you must pay for a health care service, supply, item or prescription drug
            You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.

            https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf

            Reply
        • susan says:

          Will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!

          Reply
          • Please when using technical terms, define them and provide a URL.
            https://cgsmedicare.com/parta/pubs/news/2015/0215/cope28418.html

            CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to conservative treatments.

            Pre-surgical physical therapy progress notes are important in demonstrating how the patient has progressively worsened over a period of time. Noting that the patient has “failed conservative therapies” in the history and physical is a conclusive statement and should be supported by other specific, objective information in the patient’s medical record.

            *****
            https://cgsmedicare.com/parta/mr/pdf/total_knee_fact_sheet.pdf

            One or more of the below conservative treatments have been tried and failed for 3 months or
            more except in special circumstances where delay of definitive care is not appropriate:
            • Anti-inflammatory medication:
            Duration of treatment
            • Analgesic
            • Home exercise: Duration of treatment
            • Physical therapy: Duration of treatment
            • Use of cane or walker: Duration of treatment
            • Weight loss: Duration of treatment
            • Brace: Duration of treatment
            • Cortisone shot(s): Duration of treatment
            • Visco-supplementation: Duration of treatment

            *****

            https://www.mass.gov/files/documents/2018/05/30/mng-knee-arthroplasty.pdf
            A summary of the non-operative, conservative treatment(s) that have been tried and have been unsuccessful in managing the patient’s condition;

            *****

            • A listing, description and outcomes of failed non-surgical treatments, such as:
            – Trial of medications (for example, Nonsteroidal anti-inflammatory drugs (NSAIDs)).
            – Weight loss.
            – Physical therapy.
            – Intra-articular injections.
            – Braces, orthotics or assistive devices.
            – Physical Therapy and/or home exercise plans.
            – Assistive devices (for example, cane, walker, braces (specify type of brace), and orthotics) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf

            Reply
  5. I have a dental claim that was denied as the Insurance Company says I didn’t have 12 months of coverage as mandated in the policy.

    A 12-month waiting period applies to all Major Services Page 1 of EOC

    My first appeal was denied as the Appeals Review said:

    You have requested that xxx Insurance Company waves the waiting period and reprocess the claims referenced below to allow benefit coverage. We are unable to approve your request.

    During the research of your concerns it was determined that the waiting period has not been satisfied. As stated in your plan’s Evidence of Coverage (EOC) there is a 12-month waiting period before xxx Insurance will pay for major services.

    I want to file another appeal, as the Insurance Company should have it in their records that I’ve had continuous coverage since 2014. The appeals court should find in my favor as the Insurance Company should just pay me, as their records should show that!

    • I don’t think so. The Insurance Company has clearly stated in unequivocal terms that you had a lapse in coverage from 9.30.2019 to 8.1.2020!

      Sure, their records are wrong as you have cancelled checks and I have my commision statements. If you’re going to take this to Appeals, Complaints with Department of Managed Health Care or Small Claims Court, the burden of proof is on you.

      Please review the Appeals Guides above.

      Here’s some excerpts:

      It is important to remember that you do have rights which are described in your insurance policy handbook.

      A health insurance policy is a contract between you, the policy holder, and the insurance company. A denial is a “contract dispute,” and your appeal must be based both on the reason for the denial and provisions in your insurance policy, contract

      Your health insurance plan must notify you in writing of the reason they did not authorize a specific request or denied payment of a service as well as how to appeal their decision

      One of the most important elements of your appeal packet is a clear, concise letter that addresses very specifically the reason of the denial, and incorporates the terms of your policy (or plan language). Patient Advocate.org

      Gathering the Documents You Need

      Prepare for the hearing by gathering any evidence that will help the judge understand the case. Your evidence may include any written contract, receipt, letters, written estimates, repair orders, photographs, canceled checks, account books, advertisements, warranties, service contracts, or other documents. Like your Insurance Brokers Commission Statements. Small Claims Guide

      Please also review these other pages on our website:

      Read the policy, denial letters and other correspondence like where the Insurance Company said that your coverage was lapsed three times and then when you think you understand it, read it again.

      Our webpage on the important of reading the EOC Evidence of Coverage

      Court case stating a policyholder must read their policy.

      Insurance Companies give the wrong answer and then tell the Department of Insurance that an application was never sent in, when they told the agent it would be denied and not sent in

      I’m not practising law or giving legal advice. I’m just showing you research.

      We are not interested in what someone is alleged to have told someone else over the phone

      Don’t get caught off guard at the appeals hearing or small claims court, make sure you have the evidence that the Insurance Company will show to defend their denial of your claim

      • Nah, Steve,

        You’re wrong. I didn’t have to do all the work you said. Blue Shield is paying my claim!

        we have approved your request for payment of claims on September 7, 2020 and September 14, 2020, for $737.00 per claim

        • Sorry, no.

          Please read the entire letter:

          It is important to understand that this decision has been made on an exception basis and, in making this decision, Blue Shield does not waive any of its rights to enforce the provisions of the enrollee’s health plan. Your dental plan requires that you have continuous coverage for 12 months prior to any major dental services are covered. You had two months of coverage from August 1, 2020 through September 30, 2020

          Let’s be clear what exception means:

          The definition of an exception is something that is outside of the rules or outside of the normal expectations.

          An example of an exception is when you are normally supposed to be home by midnight but your parents let you stay out until 1 AM, just for one night. https://www.yourdictionary.com/exception

          There will be no exceptions to this rule. https://www.merriam-webster.com/dictionary/exception

          I ask that you grant an exception in this case

          I understand my current policy is not obligated to pay for this, but I would like to request an
          exception.

          Health Insurance Appeals and Exception Requests https://www.insurance.wa.gov/sites/default/files/documents/appeals-guide_0.pdf

          Thus, if you have any more claims for major work, it WILL NOT be paid!

  6. I’m having a problem finding a lab that’s approved by my Insurance Company. It’s not clear if the lab in the same medical group IPA where my doctor PCP is. I’m waiting to hear back.

    What if my illness gets worse?

  7. My Medicare Advantage plan, with United Health Care denied coverage for a home health care nurse who came to our house two or three days a week for almost four months.

    I was being treated by Wound Care at Mission Hospital in Asheville, NC. Because I live 75 miles away from them, the doctors authorized a home health nurse and had me come in one day each week and later every other week.

    It was a great service since my husband is 88 and cannot drive the 150 mile round trip and my injury was to my right ankle so I was not supposed to be driving long distances.

    I have read that Medicare Advantage plans often deny this coverage although Medicare provides it.

    Any advice for appealing this???

    • Well let’s research the issue first:

      Surgical dressing services

      Medicare Part B (Medical Insurance) covers medically necessary treatment of a surgical or surgically treated wound.

      Your costs in Original Medicare

      You pay 20% of the Medicare-approved amount for your doctor’s or other health care provider’s services. You pay a fixed Copayment for these services when you get them in a hospital outpatient setting. The Part B deductible applies. You pay nothing for the supplies. https://www.medicare.gov/coverage/surgical-dressing-services

      UHC Bulletin on Wound Care This bulletin is beyond our paygrade… Try the links above.

      Home health aide services: Medicare will pay for part-time or intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting
      skilled care
      . Skilled care includes:

      ■ Skilled nursing care
      ■ Physical therapy
      ■ Speech-language pathology services
      ■ Continuing occupational therapy, if you no longer need any of the above

      Medicare & Home Health Care # 10969

      Medicare Benefit Policy Manual

      Medstarvna.org Wound Care at Home

      Medically Necessary – means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion:
      • In accordance with Generally Accepted Standards of Medical Practice.
      Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness.
      Not mainly for your convenience or that of your doctor or other health care provider.
      • Meet, but do not exceed your medical need, are at least as beneficial as an existing and
      available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively.

      Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

      Home Health Care – Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart in Chapter 4, Section 2.1 under the heading “Home health agency care.” If you need home health care services, our plan will cover these services for you provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements, or full-time nursing care at home.

      Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Our webpage on Medical Necessity

      Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

      Prior Authorization – Approval in advance to get covered services or certain drugs that may or may not be on our drug list (formulary). Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary.

      Page 273

      Send me copies of your actual bills and the denials… It doesn’t look hopeful at this time. Did you follow the appeals procedure for UHC?

  8. I recently had an appt to establish care with a primary physician after 3 yrs without. Various tests were done to assess my current health.

    I was surprised that all were not covered as part of a well woman visit or as preventative screenings.

    A test for Hep C antibodies was covered but the Hep C detection test was not.

    Blood test for lipids and triglycerides was covered but not for other blood chemicals.

    I would suspect both were necessary to provide a health profile.

    The Dr. noticed a bulge of sorts by my naval so she ordered an Abdominal Aortic Aneurysm ultrasound which was not covered.

    The AAA test is covered under the Affordable Care Act and I met four of the risk factors for checking so why was that not considered preventative screening.

    I have filed a grievance but wonder if there’s more info I need to submit from the Doctor as to why the various tests were done.

    • We are talking about what ACA defines as preventative care. Not “establishing” care or “assessing current” health.

      Here’s what is listed as preventative care:

      healthcare.gov

      Blue Shield’s List

      Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92

      If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016 Our webpage on Preventative Care

      Medical Necessity

      Clinical Guidelines

  9. My Insurance Company requires that claims be reported within 90 days. My doctor didn’t meet the deadline, what can I do?

    • Here’s what we found in the Health Net Bronze PPO Enhanced Care:

      GENERAL PROVISIONS
      NOTICE OF CLAIM: Written notice of claim must be given to Us within 20 days after the occurrence or commencement of any covered loss, or as soon thereafter as reasonably possible

      PROOFS OF LOSS: Written proof of loss must be furnished to Us at P.O. Box 9040, Farmington, MO 636409040, in case of claim for loss for which this Policy provides any periodic payment contingent upon continuing loss, within 90 days after the end of the period of time for which claim is made; in the case of claim for any other loss, written proof of loss must be furnished within 90 days after the date of the loss. Failure to furnish such proof within the time required will not invalidate or reduce any claim if proof is furnished as soon as reasonably possible. Except in the absence of legal capacity, however, We are not required to accept proofs more than one year from the time proof is otherwise required.

      ****************
      Google Research

      Investigate when claim was filed, etc. etc. with your doctor and insurance company… Nerdwallet

      **********

      what if the doctor’s office fails to file the insurance claim?
      What if the doctor files the claim after the normal 90-day insurance claim deadline?
      Do I still owe the doctor for services that would have been covered under insurance but, due to the negligence of the doctor’s office, are now unpaid?

      appeal the coverage denial. In life, the squeaky wheel gets the oil. Start squeaking.

      Obtain a copy of the late claim filed with the insurance company and a copy of the coverage denial letter. The court will be interested in seeing a letter denying an untimely claim submitted by the very doctor who assigned the debt to a bill collector.

      If you do not receive an Explanation of Benefits within 60 days of seeing a doctor, assume something is wrong and contact your insurer and the doctor’s office.

      Sam Turco Law

  10. Steve,

    My check has cleared … they should have it in there records… the last time the same thing… it was received and posted but the account was not updated …. November check has also been sent

    is it so hard to call the carrier and say… “my client is listed as cancelled yet you have received payments…can you tell me why the account is listed as cancelled or what is needed to correct the matter”

    …seems simple and fast…or would you rather wait until I search through cancelled checks to “prove” what is already known?

    • I really don’t like the telephone to deal with anything of a business matter. I much prefer email. When we approach an Insurance Company I like to follow the advice given above and get all our facts and ducks in a row first and be able to clearly express it to the Insurance Company and if need be to show clear concise emails, documents, cancelled checks, whatever is relevant to the Judge or regulatory authorities.

      The reply from the Insurance Company to your email clearly shows the point I’m trying to make.

      You will have to work with Collections to see if you can get your group reinstated. I show that we did not receive your October premiums by 10/31/18 and that is why you were cancelled.

      We have not received your November payment. I have done an audit on your account see attached.

      Collections 800-xxx-2525
      Thank you

  11. I have had many problems sense I was injured

    I have been a victim of medical malpractice

    and my lawyer also had taken advantage of me even with all my notes and complaining to everyone I could think too

    I got ignored and with all my problems

    took long to be able to feel like I can think and healed about all I am going to now

    I suffer and am in desperate need to have answers

    my medical records where compromised leaven me to suffer and

    my lawyer faild me and destroyed all hope for me

    I was double charged and now I can’t work

    waiting for disability

  12. I STARTED a POLICY ON FEB 1 EFFECTIVE DATE AND [I] CANCELLED MY POLICY DUE TO UNHAPPY SERVICES ON MARCH 2

    THEN WHY DO THEY WAIT TO TERMINATE ME UNTIL APRIL AND DO NOT GIVE ME A REFUND OF MY MONEY .

    • 1st off, you probably upset the Insurance Company, using all caps in your correspondence with them. Net Manners.com

      2nd I had to read your email several times and do major edits before I could understand your question.

      3rd – I don’t know what kind of a policy you are talking about.

      I will assume it’s individual health insurance. In our speciment policy page 22 it says that the agreement is monthly. Thus, when you cancel on March 2nd, you are covered for the rest of March and the policy can cancel the last day of March, NOT March 2nd.

      See also the explanation of Monthly premiums on page 32.

      See page 34 on the effective date of termination, which clearly says termination is the last day of the billing period that your termination was received.

Leave a Reply

Your email address will not be published.