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Insurance approval for out of area coverage

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  • Insurance approval for out of area coverage

    [Insurance approval for out of area coverage]

    Author: Sue Harry (---.208.31.117.Dial1.Tampa1.Level3.net)

    Date: 07-31-02 10:09

    I was diagnosed about 10 years ago with "IHSS". I recently had my first hospitalization for atrial fibrillation. My Dr. feels I need to consider surgery or ablation which is not done in my area.

    For 2 weeks now I have been dealing with the Dr. office and calling the insurance company to see about approval. So far nothing has happend. I would appreciate any advice, suggestions, words of wisdom, whatever--- that I could share with my Dr. I guess the delay is from him in getting the letter of justification to the insurer.In the past I have heard some comments on how difficult it is to get pre-approval for some things. I am really concerned about how they will look at this request to go to the Cleveland Clinic and see Dr. Asher or Dr. Lever.

    I work for a health care system and my insurer is a PPO.

    I will appreciate any advice you can give as how to best proceed with this.

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Sarah B-Board Moderator (---.ipt.aol.com)

    Date: 07-31-02 11:56

    Dear Sue

    If you are in a PPO, this should not be such a big deal. However, if the doctor himself is not sending the letter, there is nothing the PPO can do about it. I would talk to Lisa about this personally since she deals with this all the time and can give you some specific info that would be better suited to the phone than the message board.

    Take care

    Sarah

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    [Re: Insurance approval for out of area coverage]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 07-31-02 15:13

    Sue,

    If it is a PPO why are you waiting for the Dr to get approval? Is Cleveland out of your PPO network? If so, call Cleveland tell them you want an appointment and why and ask if there is someone there to assist with insurance issues.

    let us know how you make out.

    All the best!

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Sue Harry (---.58.237.12.Dial1.Tampa1.Level3.net)

    Date: 08-02-02 02:32

    Hi Lisa,

    I am waiting for my Dr. to write a letter of justification( or send in some form) to the insurer so they will approve me seeing someone outside of our approved network. The people at the insurance office said the Dr.'s office should know how to go about doing this. Yet so far I have had to sort of spoon feed them information about the process as I know it. I am again waiting for the nurse to call me back about the status of the letter to the insurer. They call it out of service area provider coverage and all the info I have so far stresses I had better have an approval in writeing before I do anything or I could be stuck with out of pocket expences. I am sure our system is called a PPO. Maybe I should check.

    I will call again tomorrow to see what has happened. I may call you Monday as Sara suggested if I don't hear anything tomorrow.

    Thanks for your help. Sue

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Sue Harry (---.208.30.54.Dial1.Tampa1.Level3.net)

    Date: 08-02-02 15:20

    Lisa,

    I have just been informed I have been denied an out of area referral. I also discovered the health system I am insured by is an HMO. Guess that answers some of the questions I had about the process. It seems we were a PPO in the past before many changes took place and our system expanded.

    I had a long talk today with the staff at my Dr.'s office. What a run around they got all this past week trying to do what they were told to get this squared away for me.

    I will be calling you Monday to discuss this further. I am so grateful for your support and assistance. -------- Sue

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Jerry Salzman (---.indy.rr.com)

    Date: 08-02-02 23:12

    Sue,

    I am too under a HMO. My PCP was able to get a consult from Cleveland Clinic for me but no tests. He went to the medical director. I also have talked to the HMO (I know someone in the right position) about myectomy surgery and the comment is if a local doctor is willing to do the surgery, then forget going out of the network. I plan to go ahead and get the consult and try to get surgery at Cleveland if suggested. If I get denie, I intend to fight. I suggest you do the same. The HMO should have a denial process. Can you change insurance during open enrollment? That is one option I have, however that means waiting until January.

    Jerry

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Sue Harry (---.59.85.9.Dial1.Tampa1.Level3.net)

    Date: 08-04-02 09:19

    Jerry,

    Thanks for your information. I will follow an appeal process as I have been advised. Also plan to speak with Lisa for some guidance. From what I was told by my Dr. office they faxed 2 recent ECHO reports and my Dr.'s progress note. I feel a further letter of justification may be needed with more detail to address this issue.

    I will stay in touch. ------------ Sue

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 08-04-02 19:27

    Sue,

    Call me at around 6pm EST Monday night. I will keep the time open for you.

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Sue Harry (---.208.28.72.Dial1.Tampa1.Level3.net)

    Date: 08-05-02 11:00

    Dear Lisa, Thankyou so much!! I will call you at 6pm EST tonight. I am so worried about all this, but feel such relief just knowing I will have some guidance from you. ------ Sue

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insurance approval for out of area coverage]

    Author: Lisa Salberg (208.47.172.---)

    Date: 08-05-02 13:05

    Sue,

    Glad to help!

    Lisa
    NOTE: This is a post from the previous forum message board.

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