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Insurance no benefit determination letter

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  • Insurance no benefit determination letter

    This isn't my first rodeo. I double , triple check I'm covered for medical care, treatment protocols, labatories, (did you put correct code for this blood work??) Are you sure you are In network care because you aren't listed on insurer's site?) I confirm with insurer, 3 party contractor, benefit plan, pharmacist, and "care coordinator". Tonight, the eve of my brain, thoracic, and cervical spine Mri, bleary eyed i re-reviewed my approval letter from my "utilization servicer" of my health insurer. My neurologist coordinator worked with the MR imaging center and had previously called me to tell me my co-pay and that I had been approved. So I wasn't concerned, but, I can't afford to have A non covered service. The letter was a typical form letter stating my dr had requested a service listed above and that the purpose of the letter was to "confirm" I had "given medical management the proper notification required by my contract and that the service provider" was a participating provider. It goes on to say this notification is only valid for 90 days. After a lot of redundant verbage the letter goes on to tell me that the "letter does not guarantee claims payment", "no benefit determination has been made at this time" and among other things any additional planned service isn't approved and don't forget some doctors are out of network in some states, and one can not exceed lifetime maximum benefits.

    Ok. So I called my health insurer for clarification. I have been approved for code # 70553 Mri of brain stem only. Have I been approved for any other parts of the brain or spine? No. But I am told I also wasn't disapproved. It was only coded approval for the brain stem, so the Mri of anything else is on me. But, I have a copy of the mri order in front of me. Doesn't matter said "utilization reviewer" your dr will need to request the rest of brain and spine and it will need to go through our review process.

    Hummm. What is more amusing--The irony that the letter Is "to confirm" that I notified the medical management of my pending MRI, that a letter had to be written by 2 lawyers and stamped and mailed and read by me but says and commits to nothing, or that someone decided to approve a mri of my brain stem but not the rest of my brain?

  • #2
    Jeezo. That's basically all I can say, Suebee.
    Dave Bexfield


    • #3
      Dave, I can only laugh at the absurdity.

      By way of follow-up. I spoke with the MRI insurance coordiantor at the medical center and was assured that my health insurer covered me for the 3 MRIs, and that she had spoken to me on the phone and sent an email to that effect. I requested for my insurer to be contacted again, and she seemed a little exasperated with me, but agreed. I also asked the receptionist upon arriving at my appt. yes, I was told to trust them.

      Here is the excerpt of the text of my MRI center approval letter:
      "...This estimate is based on the current treatment plan outlined by your provider and the benefits defined by your insurance company. Benefits specified by your insurance company are not a guarantee of payment for services. Any change in your treatment plan or how your insurance company processes your charges may result in a higher out of pocket expense for you."

      Hopefully, everyone will do as expected. Just in case I think we should all add the following below our signature line for consent:
      The above signature is acknowledgment by the insured that he/she has been notified there is a possibility of receiving health care that was initially thought to be covered by health insurance as prescribed by the health contract in existence from the insured's continued payment of costly premiums and co-pays, but in the event of miscoding the diagnosis, missed fax, incorrect filing, alien invasion from mars, or other act of god, the health insurer may refuse to pay, and the health care center, who pays the insurance coordinator to verify coverage, will be happy to set up a finance plan or put a lien on your home in non-homestead states.