Question

Does anyone have experience appealing a claim denial regarding medical expenses for your pregnancy/birth?  

Answer 1

Oh my goodness. That is nuts. This is when I would start getting legislator involved.  

Comments

@disabuse for what? From what I gather, she used an out of network doctor. And chiropractic care is usually not covered/only partially covered by insurance.  

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@jetty Please note the timing on my comment — posted before the more detailed explanation. That being said, a legislator and a Secretary of State can be of great assistance with insurance issues.  

Answer 2

Experience with denials not with birth. What are they debying?  

Comments

@interpellant171 I used a midwife and got chiropractic care that were not in network.  

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@rendezvous did you know going in they weren’t in network?  

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@interpellant171 yes I knew going into it. It was worth it to me to pay for those services. I’m submitting the claims on my own, even to just get partially reimbursed. I’m just trying to maximize my reimbursement.  

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@rendezvous ok good deal! That is the smartest thing to do. You could also write a letter requesting the providers be paid as in network for reasonings listed. A lot of times they will review and approve just because you asked

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@interpellant171 do you have an recommendations as to what reasons I should list for the providers being paid out as in-network?  

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@rendezvous say that you were more comfortable with the provider and felt they were more apt to handling her birthing process better. Give them the exact reasoning you chose them to begin with. Maybe they were closer to your home or hospital choice.  

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@interpellant171 perfect, I will do that! So helpful, thanks so much!  

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@rendezvous yes ma’am! It’s worth a shot. The worst thing they can say is no.  

Answer 3

What is the reason for the denial?  

Comments

@distressful right I’m just planning to appeal to see if I can get more back.  

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@rendezvous it can’t hurt to try  

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@rendezvous does your plan have a co-insurance?  

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@jetty to my knowledge, no. I don’t believe I have any patient responsibility on my plan at all.  

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@rendezvous thats a pretty amazing plan, then! I would be thrilled with a $1, 000 bill for pregnancy and birth. As far as appeals go, I was told they almost always deny the first time because they assume people will give up.  

Answer 4

What are they denying?  

Comments

@entree I used a midwife and got chiropractic care that were not in network.  

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@rendezvous Unfortunately, OON is going to be difficult to fight but, with that being said, it wouldn’t hurt to attempt to appeal it. Be sure to include reasons to support the need for the services and try to find your insurance companies policies which specify their coverage indications - it may help you with your wording and support. I wish you luck, my friend!  

Answer 5

What’s the reason for denial?  

Comments

@cryoscopy I used a midwife and got chiropractic care that were not in network.  

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@rendezvous yeah, out of network is gonna be hard to fight. I’d probably try to appeal just because using reasons given in other responses but ultimately your responsibility to ensure in network providers. I wish you the best of luck with it!  

Answer 6

The only way they will pay it if it’s in network. It’s your responsibility to verify they are in network. You can submit for out of network benefits but usually it comes with a high deductible so you have to pay the bill anyway but it does apply to your out of network deductible. Also, if you work for a company that is self insured you can request for services to be covered but it’s hard and that’s unusual. Most ins plans are not self insured. I worked in medical care for over 15 years and saw this all the time unfortunately.  

Answer 7

I worked at a chiro office doing billing and if it's not a covered benefit they won't approve it. If it was denied for other reasons then maybe. Do you have any more details?  

Comments

If it is a covered benefit under out of network benefits than you 1st need to find out the specific reason for denial.  

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@popgun the claim response I received said it wasn’t covered under my plan benefits but my plan says I have 35 visits/year? I’m assuming it’s referring to OON plan benefits but all my services are at no out-of-pocket responsibility for me so that shouldn’t make a difference.  

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@rendezvous 35 visits for chiro care? If so it might have been submitted with the wrong ICD 9 codes

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Or maybe requires a referral from you're primary doc?  

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@popgun they lump all rehab/chiro into 35 visits yearly max. I’ll have to call to verify why it wasn’t covered. I’m appealing my midwife denial too. Just wanted to get some insights here first. Thanks.  

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@rendezvous yes definitely do appeal and see if the chiro office can share the specific codes they would bill it can be as simple as 1 number on the code or proper diagnosis that matches your billing codes. I'm happy to help you further. DM me if you like.  

Answer 8

Hello! I had a home birth with a CPM out of network (who was serving as my doula) after planning to give birth with another midwife practice at a local hospital. When we called Care First, a very nice woman told me to appeal with a written letter making my case. I kind of gave up on it after they “denied my appeal” soon after. Much to my surprise, I got a check from CareFirst for $1250 reimbursing me for part of the $4500 birth that I had paid out of pocket. Doesn’t hurt to make your case. Good luck! ❤️