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How do you read this insurance letter?


Ann.without.an.e
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We have been going back and forth with insurance on this.  I am so done.  

The doctor has submitted everything and this very, very expensive treatment was approved for DS (and super necessary right now).  It doesn't say "we will consider approving it".  Right?  The insurance keeps running us around on this now.  They are like, "well, we never promised covered and we still need to consider the necessity of the claims".  This is why we sent in medical records and got the authorization, right?  And they keep asking for more info to determine whether they might cover it?  They've already sent a letter of coverage.

I just don't get it.  I am baffled.  DS has his 3rd infusion tomorrow. These things are like 14,000-20,000 an infusion and the insurance refuses to process the claims because they aren't sure they want to cover it now??

 

 

Image 8-7-19 at 8.00 PM.jpg

Edited by Attolia
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5 minutes ago, Æthelthryth the Texan said:

I read that to say You Are Approved. I mean it says "This approval" right there- maybe highlight that and send it back to them?!? 

I'm sorry because I know how frustrating that is. They did something similar with my knee surgery. I feel like there is a magic 8 ball in charge of the insurance claims dept. 

 

I keep referencing the approval letter and they keep saying, "well, that doesn't necessarily mean it is covered, it just means we've considered it".  What does that even mean?  And the letter doesn't say that?  It says APPROVED.  Sorry, I just needed to vent.  I try not to yell at the poor customer service people at UHC because Lord knows they didn't create this broken system.  

Edited by Attolia
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I would interpret it as you can have 10 injections of whatever at that particular place specified as an outpatient and that they’ll cover it except for your copay, deductibles, coinsurance. )what’s coinsurance mean?) 

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Yuck. It sounds like it is carefully worded to allow them the option to later deny. The service "is eligible for outpatient coverage." It doesn't say it's covered, just that it's eligible to be covered. In other words, yes, this can be covered under your plan depending on specifics.

That said, I definitely would have interpreted this as approval.

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3 minutes ago, Jentrovert said:

Yuck. It sounds like it is carefully worded to allow them the option to later deny. The service "is eligible for outpatient coverage." It doesn't say it's covered, just that it's eligible to be covered. In other words, yes, this can be covered under your plan depending on specifics.

That said, I definitely would have interpreted this as approval.

 

 

Yes, but in insurance world that is what they call approval - eligibility.  And it goes on to say what we are responsible for.  

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5 minutes ago, Attolia said:

Yes, but in insurance world that is what they call approval - eligibility.  And it goes on to say what we are responsible for.  

Yes, and it is crazy to me that eligibility is the most you can be certain of before having a thousands of dollars procedure. 

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40 minutes ago, Æthelthryth the Texan said:

Ah so we also have UHC. I ended up sicking the state insurance commission on them. They didn't end up doing anything but it helped move things as a threat and it made ME feel better to at last do something. 

If the insurance is through you or your dh work, you might call your HR dept and see if they can help. I did that too when they were holding up my knee surgery at the last minute. 

my friend made that threat.  actually, the father of one of her patients was a huge malpractice? lawyer in their state and he offered to send a letter (pro bono) to the insurance company offering a front page story in one of the largest papers in the country.   they coughed up the money for her infant grandson's bone marrow transplant.

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I read this as "this a service this insurance company does pay for" but also "you may still need a referral from your doctor per your plan rules".  I don't see that they say the referral was approved. Just eligible. These together make me think that this is just a benefit that the insurance company does pay for, but it hasn't been completely approved by your individual plan yet.

I also read this as "if you get the referral and approval to start treatment, this is the qty of injections and dates we will pay for. It seems to just quantify what the insurance will pay for....upon approval.

I would not read this as a letter of absolute coverage.  To  be fair....my daughter's have had multiple years of over 100,000 in billing per year. The double speak in insurance is sooooo frustrating!!!!! And 100% in their favor. I spend 20 minutes on the phone almost every.single.day talking to doctors,insurance companies, pharmacies, medical providers. I have learned the lingo.  Any letter of approval from an  insurance company I have received was crystal clear. This letter is vague, so I would not read it as a "book the appointment, we will pay". 

Edited by Tap
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I think it’s a letter indicating eligibility for benefits.   It is not an approval letter.  To help make this clear:

a few years ago, I had shoulder surgery and needed physical therapy afterwards.  My doctor did a referral and I got a letter like this verifying that Yes, PT was an eligible benefit under my insurance and if approved, the benefit covered X visits.  Then, the PT office put in for pre-authorization/pre-approval and I got a second letter that stated I was Approved for X sessions at that location.

I think you should reach out to the facility doing the injections and talk to them about getting a pre-authorization for the service before you begin treatment.  With this eligibility determination already in place, getting the pre-auth should be fairly quick.

On our insurance, only outpatient things and high dollar expenses requires the 2 part process. I am sure other companies can handle it with just a single letter, but ours seems to have different groups that handle eligibility vs approval.

 

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13 hours ago, Tap said:

I read this as "this a service this insurance company does pay for" but also "you may still need a referral from your doctor per your plan rules".  I don't see that they say the referral was approved. Just eligible. These together make me think that this is just a benefit that the insurance company does pay for, but it hasn't been completely approved by your individual plan yet.

I also read this as "if you get the referral and approval to start treatment, this is the qty of injections and dates we will pay for. It seems to just quantify what the insurance will pay for....upon approval.

I would not read this as a letter of absolute coverage.  To  be fair....my daughter's have had multiple years of over 100,000 in billing per year. The double speak in insurance is sooooo frustrating!!!!! And 100% in their favor. I spend 20 minutes on the phone almost every.single.day talking to doctors,insurance companies, pharmacies, medical providers. I have learned the lingo.  Any letter of approval from an  insurance company I have received was crystal clear. This letter is vague, so I would not read it as a "book the appointment, we will pay". 

 

12 hours ago, AK_Mom4 said:

I think it’s a letter indicating eligibility for benefits.   It is not an approval letter.  To help make this clear:

a few years ago, I had shoulder surgery and needed physical therapy afterwards.  My doctor did a referral and I got a letter like this verifying that Yes, PT was an eligible benefit under my insurance and if approved, the benefit covered X visits.  Then, the PT office put in for pre-authorization/pre-approval and I got a second letter that stated I was Approved for X sessions at that location.

I think you should reach out to the facility doing the injections and talk to them about getting a pre-authorization for the service before you begin treatment.  With this eligibility determination already in place, getting the pre-auth should be fairly quick.

On our insurance, only outpatient things and high dollar expenses requires the 2 part process. I am sure other companies can handle it with just a single letter, but ours seems to have different groups that handle eligibility vs approval.

 

 

Everything has been submitted, the doctor's office received approval.  They sent in all of DS's medical records already, filled out everything necessary and had the pre-authorization to start treatment.  They said they wouldn't have started treatment otherwise.

Edited by Attolia
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9 hours ago, Attolia said:

 

 

Everything has been submitted, the doctor's office received approval.  They sent in all of DS's medical records already, filled out everything necessary and had the pre-authorization to start treatment.  They said they wouldn't have started treatment otherwise.

Maybe they did, but I don't think this letter is the letter that proves it. Does the doctor's office have a different authorization letter?

 

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On 8/7/2019 at 6:58 PM, Attolia said:

We have been going back and forth with insurance on this.  I am so done.  

The doctor has submitted everything and this very, very expensive treatment was approved for DS (and super necessary right now).  It doesn't say "we will consider approving it".  Right?  The insurance keeps running us around on this now.  They are like, "well, we never promised covered and we still need to consider the necessity of the claims".  This is why we sent in medical records and got the authorization, right?  And they keep asking for more info to determine whether they might cover it?  They've already sent a letter of coverage.

I just don't get it.  I am baffled.  DS has his 3rd infusion tomorrow. These things are like 14,000-20,000 an infusion and the insurance refuses to process the claims because they aren't sure they want to cover it now??

 

 

Image 8-7-19 at 8.00 PM.jpg



I did rituximab infusions,  and  like his, wicked expensive.  We got one of the infusion bills pushed back too.  The hospital resubmitted.  They had prior auth.  Assuming yours does too, you won't be on the hook for it - either insurance will (likely) or the hospital (less likely) but this isn't yours.

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It means that generally this is a medication covered by your policy. That's what it means by "eligible." Whether or not it will be covered for this particular patient for this particular diagnosis on a specific date has not been determined. They won't make that determination until after they actually receive a claim. This is a fairly common document. They are saying that, in theory, it is covered, but they aren't going to decide until they actually get a claim. Things that could impact their decision could be: the patient no longer has their insurance, the medication is not covered at the time the infusion is received (they have dropped it from their formulary), the medication was not provided by their preferred pharmacy or that they the information submitted with the claim doesn't support medical necessity.

 

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On 8/7/2019 at 8:13 PM, Jentrovert said:

Yuck. It sounds like it is carefully worded to allow them the option to later deny. The service "is eligible for outpatient coverage." It doesn't say it's covered, just that it's eligible to be covered. In other words, yes, this can be covered under your plan depending on specifics.

That said, I definitely would have interpreted this as approval.

 

Yes, it is carefully worded to give them the option to deny later. Only documents that say "prior authorization" are actually authorizations, and even then, there are dozens of reasons why an authorization would be given and the service or supply end up not being covered in the end.

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On 8/7/2019 at 8:13 PM, Jentrovert said:

Yuck. It sounds like it is carefully worded to allow them the option to later deny. The service "is eligible for outpatient coverage." It doesn't say it's covered, just that it's eligible to be covered. In other words, yes, this can be covered under your plan depending on specifics.

That said, I definitely would have interpreted this as approval.

 

I agree with what you wrote, except I would not have definitely interpreted this as approval.  There are some medical procedures that are flat out not covered for some plans.  This letter is just saying that, Yes we do cover this type of treatment, but we’re not yet sure we’ll cover it for YOU because we need to review the medical necessity (or other things) of it.

For example, I worked for a health insurance company and some plans for Catholic groups specifically excluded abortions as covered procedures.  And we had another plan for a certain college that specifically excluded any treatment that came in for the diagnosis of genital warts.  So this letter is simply saying, “Yes, this is a service that is covered, as long as all your medically necessary ducks are in a row.”  This letter does not address whether your ducks have been found to be in a row.

On 8/7/2019 at 9:02 PM, Tap said:

 

I also read this as "if you get the referral and approval to start treatment, this is the qty of injections and dates we will pay for. It seems to just quantify what the insurance will pay for....upon approval.

 

 

I do not think this letter means that if they get approval to start treatment that they’ll pay for that qty of injections.  The chart says those are the “requested” number of injections.  Not the amount they may actually pay.  Underneath it spells out that there might be limits on the number of services that are covered.

11 hours ago, Attolia said:

 

 

Everything has been submitted, the doctor's office received approval.  They sent in all of DS's medical records already, filled out everything necessary and had the pre-authorization to start treatment.  They said they wouldn't have started treatment otherwise.

 

Hang on...if the doctor has the approval and the pre-auth, then is there a problem?  Have you received a denial for a submitted claim?  Or did you call them to confirm that everything was a go and that’s when you started getting pushback?   I’d ask to see the approval information from the doctor’s office if possible and keep a copy for your records. 

 

Edited by Garga
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