Sunday, February 22, 2009

first rejection is IN!

I got my first rejection letter today.

Dear Dr. Lee,

Thank you for the pre-authorization request for Stephanie R. Sheppard.

Your request has been reviewed, and it has been determined that the Lefort I, mandibular and maxillary osteotomy and related services cannot be approved. The member's health plan specifically excludes treatment for, or any appliances used in connection with, myofascial pain syndrome, malocclusions or other abnormalities of the jaw.

We regret that we are unable to provide you with a more favorable response, however, we are obligated to administer our health plans consistently and according to their terms.

If you disagree with our decision, you have the right to request a review either verbally or in writing. This is the first level of the appeal process. Enclosed is an overview of this process. A complete description of the member appeal process is available upon request, free of charge.

If you have any questions, please contact Provider Customer Service.

Correspondence Coordinator.

The overview for the regular process first level appeal is that I have 180 days from when the letter was written (January 26th, though I just got this in the mail today) to request a review. They will then send me a description of the entire member appeal process according to my specific plan. The first level review is done by a Grievance Coordinator and a decision will be made within 30 days. After that, there are "Subsequent Levels" where I can further disagree if they deny me again - and request further information about additional referrals.

I'm not exactly sure how my school district fits into this - I know that they can ultimately make a decision and override my insurance if I appeal through them, but I'm not sure how many official insurance appeals I have to go through first. We'll see.

Here we go!


Ananda Devika said...

Good luck!

laura said...

What BS. Good luck! The migraines alone should be enough to get you approved, surely.

Stephanie said...

Sorry to hear about the rejection letter. Let me know if I can help in any way. I went through an appeal and luckily that did the trick.