She HATES me!!!!

Okay..so, even though my appeals packet just arrived at Highmark BCBS on Wednesday, I still called today because I had this hope/dream/fantasy that I would be one of those people who could post "I'm Approved--it only took 2 days".  Obviously, not my luck.

I called the appeals administrator at Highmark and was a little cautious because in October when I originally requested preapproval and was denied (b/c I didn't have 6 months supervised) I asked them not to send my file for "appeal" until I notified them to do so.  My plan was that since I had 180 days to appeal I would just do four more supervised doc visits & then send all the documentation from my PCP to them and, since they said I had met all criteria except the 6 month supervised, I would then not have to start all over.  Unfortunately, the decided to totally ignore my 4 telephone calls/notes in my file and two certified letters stating that I was not going forward w/a first level appeal at this time & go ahead & unilaterally decide to appeal it with no additional documentation. Well, of course, I got a letter by mail saying "my" appeal had been denied & now any 2nd level appeal would take 6 months & have to go to the ERISA outside committee.  So, I called the appeals administrator & explained to her that I should not be at the second level appeals yet, that I hadn't requested an appeal.  She said it was done automatically. I said that my policy specifically states that the member (me) initiates the appeal.  She said I was wrong. I sent her a highlighted copy of my policy, along w/copies of letters and phone notes requesting that it not be appealed.

 She was NOT happy, but knew I was right, so she returned my file to denied status and I told her I would notify her in writing when I wanted to appeal. 

So, today I called and she answered the phone...of course, as soon as I said my name (keep in mind, I was so nervous & so excited & so hopeful) she sighed and said that she had rcv'd my packet Wednesday.  I tried to be extra charming (lol!) and asked if it was 15 days or 30 days until she made her decision and she sighed again and said that she would take the 30 days--29.5, that is--ug.  She really can't stand me. The she hung up.

My hubby says that it doesn't matter if she likes me or not because I have complied w/all the requirements and she has no choice other than to approve me.  He's so optimistic. I am scared to death that because of what happened originally & me bugging her with that, well, that now she is going to try to find a reason to deny the claim.  Neurotic, perhaps, but still....ug.

Thanks for letting me vent.....say a prayer....xo, Micheala.

Micheala you've established you know what your talking about and you keep documentation to back yourself up, I doubt she would be stupid enough to fabricate something. If anything maybe being a pain in the butt she will approve you just get rid of you, heck what ever works! Good luck I hope the time passes quickly but I know if it was me it would probably drag. C'ya Bob (Will keep good thought's)

Thanks, Bob...I guess those years in law school did have their benefits---taught me how to document the heck out of things to save my life & how to be a pain in the ass when needed!  Typically not traits required in my daily life as a stay-at-home mom (at least not for 10 more years when I have three teenagers!)  :).

 

WOW!!!  Someone's on top of things!  Good for you!

Remember this, it's your life we are talking about, not theirs'!  So, fight for your rights as only you can. 

I say kill 'em with kindness, but stay firm!

Thanks, Scott...I like that advice!!  Micheala.

I am proud of you for knowing your policy and standing up for your rights... 

I would call them everyday.  No lie.  In 30 days, I called BC every day, sometimes in the morning and afternoon.  They knew I was serious to have this surgery!  One lady told me not to call back, that i would get a letter in the mail.  I said, "This is my health, here.  I can't wait for a letter in the mail.  I will talk to you next Tuesday as I will be calling back."  (The only reason I didn't call on Monday is because it was Labor Day and they were closed!)

Be proactive and diligent!

Mel, I know, right!?!  I told myself I would wait until Monday to start calling, but I just had to call on Friday...this is so very important to me!!  I am going to follow your lead & call everyday (but maybe to customer service instead of directly to the appeals administrator---she called me once & I wrote down her number from my caller ID....that's the number I used to call on Friday--I think it was a shock to her that I had her direct line......)...thanks, Micheala.

I will share with you what I said, and what a wonderful gal commited me to do!!!  First she said don't worry if you have to call them all the time, stay on top of this,  I my response to her was, "I guess I should take the bull by the horn and hold on tight" and her response was you do just that, and everyday she would pm me or call me, somehow search me out to connect with me, to find out if I had done just that, anything she would ask, I knew I had to respond, and she should realize the impact she had on my surgery approve, she pushed, but through her pushing, I pushed backed, and love her even more for that, Her name, well lets just say you know her as TRINA, I at that time knew her as Jaded -Julie. I know that god has sent all of this board to us for a reason, each and everyone as played a part in my journey, rather they know it or not, as they will in yours. Be greatful and pass it on!!! You will be Blessed and you too will be approved quickly. Luv ya sweetie Barb

Barb--thanks so much for sharing that...what a wonderful story!  Sometimes just knowing that there are fellow-OH-ers out there knowing that I am waiting for an approval helps---you all know what it is like to play the insurance game & I am really hoping to be able to say I am approved soon!!  Your journey has been so great....inspiring!  Micheala.

I'll be praying that the Lord will send her a spirit of mercy and compassion for you!  Hang in there!