Insurance Out of Network Approval Denied...Now what???

I have Univera Senior Choice Secure Insurance in NYS. I called my in network providers and was told they only see "Bariatric Virgins"...once a surgeon does RNY on you the in network providers will not see me.  I was referred to Cleveland CLiinic in Ohio... which is a 3.5 hour drive one way...but I was and remain willing to make the trip if that's where I have to go to see a doctor for another opinion.  I am constantly hungry and can eat and drink unlimited amounts of food... so I know something is drastically wrong with my RNY pouch.  The review team of doctors for my insurance company said I can be seen "in house"... but yet when I call the list of providers they all say no. Do you think I should ask for a denial letter for an appointment at each of these clinics to prove my point?  It's probably a slim to none chance of getting such a letter but I want to get to the bottom of what's wrong with my RNY surgery. Any experts out there on how to get an approval ???? I appreciate your responses. Thanks
Kathy

www.patientadvocate.org/pdf/pubs/appeal_guide.pdf


Sorry to hear that you were denied.

All I can tell you is to NEVER give up and NEVER take no for an answer.

Good luck.

I will keep you in my prayers.

Teena,
Thanks for the support and prayers...it means a lot :-).
Hugs,
Kathy

Kathy,

Welcome.

Keep us posted.

Hi Teena,
Thanks for your post on the "Appeals Process"... lots of great information. I appreciate the guidelines so much. I appreciate the post very much.
Hugs,
Kathy

I am seeking an RNY to DS revision. My insurance company covers revisions but they want me to go back and see the original RNY surgeons, there are no RNY to DS revision surgeons in my medical group.  I had my Primary Care Physician submit a request to my medical group (I have an HMO) asking to see an out of network doctor, they denied that request.  So then I went to the medical plan itself, they also denied it.  So now I have an appeal with the Dept. of Managed Health care here in California.  Go through every appeal process available to you.

When you tell your health plan the responses you're getting, what do they say?

 

Hi Debbie,
My insurance company customer service representative told me that the in-network doctors have the option of accepting or denying you as a new patient. I explained my dilema that the in network doctors are the ones stating my only option for a "2nd opinion or revision in my area is to go to Cleveland Clinic". My problem is that the in network doctors won't give me that denial in writing. So I asked my insurance company for an out of network approval to be seen all based on "hearsay of the in network doctors" . To me it sounds like a SCAM  and total RUN AROUND. 
I will follow out the appeals processes.... but will not go back to my origional surgeon that clearly states in his words "I don't make mistakes".  Thanks for your support.
Hugs,
Kathy