Insurance: Empire BC/BS

[mbalfour]

Has anyone out there had coverage for ProTime monitoring from Empire BC/BS in New York State?

Has anyone out there been denied coverage for ProTime monitoring by Empire BC/BS in New York State?

 

[QAS Lance]

Empire BCBS

Empire BCBS

Hello,

I'm showing that we haven't had any success as of yet with Empire BCBS. That doesn't mean that they never will cover, just that we haven't had any luck. Thanks,

Lance

 

[ALCapshaw2]

The ONLY way I've found to get coverage if it is not a covered benefit is to file a cliam, have it rejected, and then file an appeal. There is NO WAY to file an Appeal BEFORE the Fact with BCBS.

It helps to have a Caseworker 'greasing the skids' and getting your case to the proper places.

'AL'

 

[mbalfour]

Empire BCBS

Empire BCBS

Lance:

FYI, you might touch base with Susan B. and Rebecca F. at QAS to see what is behind my post. They will tell you that EBCBS has approved payment for a year and then arbitrarily yanked it the following year. I am presently formulating an appeal and I will be copying your people. Thanks for the advice.

Al:

Please educate me . . . what caseworker and how are the skids greased?

 

[ALCapshaw2]

Hello again Manny,

I can't help you with any specifics because my case was handled in Alabama. All I can suggest is calling the 800 number for your BCBS coverage and ask about getting a case worker and explain your situation. In my case, I had a caseworker assigned to handle my Cardiac Rehab and I asked her about the Home Test units and she had me fill out some paperwork and had it reviewed by a committee that reviews coverage for BCBS.

Good luck and keep pestering them until you find someone who can help.

'AL'

 

[mbalfour]

Al:

The appeal is going out tomorrow. Wish me luck.

 

[mbalfour]

Good news -- won the appeal !!

Good news -- won the appeal !!

Won the appeal with Empire Blue Cross Blue Shield. The basis for my argument was the relative cost of frequent lab tests vs. the cost per test of a ProTime test (about 5:1 in favor of ProTime). Have approval for another year. Hopefully, we're starting to set precedent here.

 

[Ross]

Excellent!

 

[bvdr]

This week I just got my reimbursement check for my pro-time unit. It was initially denied but on appeal they decided to cover it. I filed for reimbursement last Oct. and it has taken this long. They also paid a portion of my initial supplies. I have ordered supplies twice since then that I never filed for but from now on I will. This was with BC/BS of North Carolina.

 

[LUVMyBirman]

Hi Betty. Great news for you! Still trying to get BC/BS of IL to cover my supplies. They did once last year and applied it towards my deductable. Since I have tried to submit with no luck.

Can you tell me how you are classifying your supplies on the form? Thanks and good luck to you! I feel we are all coming close to a breakthrough to get such covered. Once they figure out it is saving them big time $$$...I feel most carriers will come around.

PS. Hi Manny...... I see you lucked out too! Please tell us your code for getting supplies approved!

 

[mbalfour]

The key to success (this time)

The key to success (this time)

Gina:

The Buzz words are "Durable Medical Equipment" and "Supplies".
They have to be clear on the fact that you are getting supplies, not the Protime machine itself.

The Procedure codes that worked in the past are:
X6503, X6503NU and E1399.

From my discussion recently with a Nurse in the EBCBS Medical Management Department, they will readily cover SUPPLIES. Covering the machine itself is another story.

My appeal letter cited the fact that previous claims for supplies were honored and that the most recent claim was arbitrarily denied. The letter was sent via Certified Mail to their Appeals Department with copies to the NY State Insurance Board and to the NY State Department of Heatlh. I think I got their attention because the rejection was rescinded on the very day they signed for my letter. I guess it pays to rattle the cages.

 

[LUVMyBirman]

Hi Manny,

Thank you very much for the information.

Funny story. 4 years ago when I purchased my Coaguchek. My insurance carrier (Aetna PP0) covered the unit at 60% under my durable medical equipment rider. We do have this rider on our current BC/BSIL policy...problem is when they look in the computer there is not a section for supplies under the actual unit because the supplies are not durable medical equipment themselves.

I plan on giving BC/BS a call and mention your codes. See if it gets me anywhere. Especally as it appears I am going to be using a ton of stirps in the next few weeks until MY INR levels out.

Thanks again. And thank goodness for this technology!