insurance

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	First claim denied for E's first evaluation and diagnosis.  Any advice on how to handle the insurance company?  I cannot get the web address to work to find out why the denial of services www.benplan.com My husband works for a major hospital in the east and my son was seen by the rehab department within their hospital (referred to them by our pediatrician) Well, when my daughter needed speech services, our insurance wanted the school system to evaluate her first.  Their logic was, why should they pay for therapy if the school system could provide it for free?  But at the time, she was attending private preschool, so they paid for it provided we have her evaluated and monitored by the public school system.  They wanted copies of an IEP and updates every 12 months. Maybe something similar is going on in your case.  I would call them directly and ask.  Make sure you right down all call times along with who you speak to and any pertinent information discovered.  It sounds like you may have an uphill battle on your hands, but I hope not. Consult your current policy for covered benefits and contracted providers.  Obtain your explaination of benefits regarding this occurance, it should explain what happened.  It is possile it is an error in processing, but it is also a possiblity that this is not a covered benefit or perhaps your insurance does not cover non-contracted providers, even if that provider is the hospital where your dh is employed.  It could also be a dx code error, which makes a big difference if what was billed is a covered benefit.  If it turns out that you are just not covered for this particular date of service, you can always appeal it. The previous answers are pretty much right on, but since we're talking about a first diagnosis and your question is how to handle the insurance company, I want to give a slightly different version of the answer: Get to know your insurance policy very well and figure out exactly what is covered.  Research your state's laws with respect to mental health (is there a mental health parity law?) and figure out what services the insurance company is obligated to provide. If the insurance company ever denies a claim that the policy/law requires it to pay, call, protest, appeal etc. until the company backs off and pays.  Take the attitude that you will sue if necessary, knowing full well that the company will back down before that becomes necessary.  Do this once and the company probably won't mess with you again. And if something isn't covered, then it isn't covered.  Pick your fights wisely. We do have a parity law, and per the Easter Seals it stated that autism was listed as follows: North Carolina does not have a health insurance mandate for autism. Coverage for autism is provided under the mental health parity legislation (H.B. 973) that was signed into law by Governor Easley on July 27, 2007. Group health insurance plans must provide coverage for mental illnesses as with physical illnesses. Mental illnesses are defined by the Diagnostic Statistics Manual of Mental Disorders DSM-IV, and autism is included. However, group health insurance plans may establish review criteria to determine the medical necessity of the mental illness. Also, group health insurance plans may set durational limits for the treatment of mental illnesses that are different from limits set for physical illnesses. At a minimum, the group health insurance plan must cover at least thirty office visits per year or a total of 30 combined inpatient/outpatient visits per year. I received a letter from the insurance company for his OT and PT evaluation to discust review of clinical information necessary to determine eligibility.  I never received one for his evalution with a neuropsychologist.  The pediatrician referred him for services and I asked that she refer us to a DR that was within our insurance coverage.  One thing that may save us is even if the insurance co does not cover this is that it was done at hubby's work.  In some cases they will cut the bill in half and allow you to pay the bill tax free from your paycheck with a set amount by us.  The first evaluation was $2800 and with the diagnosis PDD-NOS.    Look under (Resources for Autism) Fighting insurance by NorwayMom. Good Luck! Well I have to appeal it because the code was submitted for neuropsych test but on the insurance end it was NC/LEARN/DEV/BEHA and not something they cover unless it was deemed a medical necessity.  Because the word "developmental" was in his diagnosis then the insurance company kicked it out that it was a learning delay.  UUUGGGGH!.  The insurance's own website has information from their DR's and nurses about PDD NOS and the services that are needed.  I will be printing that out and submitting it with my letter.  So I have to get a letter from the DR's stating that it was medically necessary to have these tests performed. I did find out from the insurance company that I get 30 therapy visits a year.  Not sure if that is for both PT and OT, they are going to get back to me.  Thanks for the link to the other forum with this subject matter, I am going to use that to help me write my letter to the insurance compnay.  I was sure to point out that my child needs these services now or else he will need much more later.  Still frustrated that when I did work, I worked for a Substance Abuse Inpatient Program.  Insurance, tax dollars, etc funded the resources for patients to get all kinds of help, and if they relapsed...they could go back for more help!  With this being said, I am so disheartened that insurance companies will not help a child who needs help.  I am even considering basing my vote in Nov on which ever candidate has the best position on Austism.  Here's the link Loki was talking about: http://www.autism-pdd.net/forum/forum_posts.asp?TID=18097&am p;KW=fighting+insurance
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