Hi friends. A year post my first surgery and Blue Shield of CA has finally paid my surgical claims from both surgeries! After a long battle they finally retroactively authorized the surgeries but then the fun and games really began. First they reprocessed the original claims and then once again denied them. Then they had me have Banner Health submit new claims and they denied those as well…even with the authorization in place. It was a game of procedure codes that I could never win because Blue Shield of CA wouldn’t speak directly to Banner it had to be the local Blue Shield office and they were apparently out of the loop. Anyway, with the help of the CA state board of insurance Blue Shield of CA finally gave up the game and I see on my insurance dashboard that all the claims have been paid. Now I just have to deal with Banner and the anesthesiology group to get reimbursed. Just wanted to share the good news, especially for anyone struggling with getting insurance approval.
That’s great news! I hope it doesn’t take too long for you to be reimbursed too, all sounds very stressful so glad that it’s nearly over! 
@Chrickychricky - I feel that BC of CA’s behavior is inexcusable. You pay for your medical insurance in good faith. You followed their out of network guidelines also in good faith so there is no reason you should have had to jump through the hoops they set up over & over again for a year. I think they owe you more than a reimbursement … like a major apology! I applaud you for maintaining the upper hand & finally receiving the “prize” at the end. What a ridiculous ordeal!!
Hi. I don’t know if you’re still around, but BS of CA declined to pre-authorize my surgery today, saying it wasn’t necessary. But I’m told, then they’ll just deny it later as not medically necessary, so my surgeon’s office (Dr. Costantino) understandably wants us to get Blue Shield to commit before I have the surgery. Did the CA Board of Insurance issue any sort of letter or opinion about your case, or is there anything you could share, or point me in the right direction? I’m a recovered lawyer so I can in theory do some research, but my brain fog and cognitive decline are quite legit. Ugh! So glad you got them to cover what you needed. I hope you’re feeling well now. – t.
Good morning,
I’m so sorry to hear you are going through this with them and you have to advocate for yourself when you are feeling your worst physically and mentally. I’m happy to help in any way I can. Before I launch into anything, I just want to make sure I understand it correctly. Are denying the surgery itself as not medically necessary or are they denying Dr. Costantino as the surgeon because he is not a Blue Sheild of CA provider?
I’m sorry that you’ve had the authorisation denied, I hope that you can get this sorted…Can you speak to an advocate with your insurance company, I think others have said that all companies should have one?
Hi. Sorry I disappeared - I had a big flare up of all the things.
So BS of CA declined to pre-authorize the surgery with Costantino and said it does not require a pre-auth. But then after the surgery when Dr. C submits the bill, they then reject it as not medically necessary. So Dr. C won’t do the surgery without a pre-authorization/prior determination that the surgery is indeed medically necessary.
BS of CA does NOT have any patient advocates. Because they didn’t actually DO anything yet, it’s not a clear “grievance” or appeal. I need them to get to the part where they do an Independent Medical Review.
I’m going to try to submit the grievance by phone and ask that it be expedited. And then I need to get docs to them. I don’t have any marked up imaging - Dr. C’a preauth request oddly doesn’t include any imaging screen shots or anything.
Any help/suggestions you can offer would be SO appreciated. Thanks. - tara
@tkk - I can’t remember if you posted images on the forum. If you didn’t but think annotated imaging would be helpful for your case, you can PM pics to me, & I’ll annotate them to the best of my ability so you can include some in your appeal, ether that or you can send some of the unannotated imaging you have with your appeal. Either way, a picture is worth a thousand words & might help your case.
@ninamarie1424 recently posted on this thread & her information could also be helpful for you:
They did the same thing with me because you don’t need a pre authorization for surgery in the state of CA. The problem is that it’s out of state and they don’t cover out of state unless it’s an emergency. You need to ask them for a form called “Access to Care” and have Dr. C’s office fill it out. The argument to be made is that there is no one in state with the expertise to do the surgery. Blue Shield of CA will likely deny and then you can appeal. You will probably lose the appeal, as I did, and then you can file a grievance with the Department of Managed Health Care who will help you get approved. I paid out of pocket for both surgeries and finally got reimbursed a year later with the help of DMHC. Maybe the fact that they were forced to pay for mine sets some kind of precedent? I’m sorry you are going through this.
Hi. Can I message you directly, or would you mind chatting with me on the phone? The brain fog has been INTENSE lately and I’m having trouble getting anything submitted, partly because I don’t know what I’m doing. Thanks so much, t.
This is an amazing offer and one that would help me immensely! Dr. C was so great about walking us through the CTV and plainly showing how they were compressed – I should’ve taken screen shots or recorded that somehow. The files are huge so I’m not sure how to send them. I’ll dm you now. Thank you! – t.