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JennP
LIF Adult
Member since 10/06 3986 total posts
Name:
Jenn
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Help, and I hate Aetna - External Appeal with NYS
Has anyone ever had to file an External Appeal with NYS for a claim that was denied?
It's for 13k.
I don't really want to get into details, but my son was seriously injured almost a year ago (he's fine, thank G-d.)
His skull was fractured, but of course it wasn't "medically necessary" for him to go to the hospital.
I am putting as much evidence together as I can and writing a letter, just wanted to know if anyone has BTDT and can offer advice.
TIA
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Posted 5/9/18 10:36 AM  |
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Long Island Weddings
Long Island's Largest Bridal Resource |
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Help, and I hate Aetna - External Appeal with NYS
If it’s emergency medicine even if an out of network doctor saw him, it should be covered, is this your deductible or coinsurance?
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| Posted 5/9/18 11:31 AM |
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lightblue
LIF Adult
Member since 1/17 2249 total posts
Name:
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Re: Help, and I hate Aetna - External Appeal with NYS
Isn't there something called the "surprise bill" law? I'd look into that...
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| Posted 5/9/18 11:32 AM |
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NervousNell
Just another chapter in life..
Member since 11/09 54917 total posts
Name:
..being a mommy and being a wife!
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Re: Help, and I hate Aetna - External Appeal with NYS
Wait... A skull fracture is not a medically necessary reason to visit a hospital??
Yet people use the ER as their personal Stat Health when thy have a cold?
Good Lord these insurance companies suck.
Something needs to be done.
Ridiculous
Message edited 5/9/2018 12:37:33 PM.
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| Posted 5/9/18 12:36 PM |
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JennP
LIF Adult
Member since 10/06 3986 total posts
Name:
Jenn
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Re: Help, and I hate Aetna - External Appeal with NYS
Thanks everyone.
It wasn't out of network so it looks like the surprise bill law doesn't help.
They're in our network, they're just denying it.
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| Posted 5/9/18 3:20 PM |
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Katareen
5,000 Posts!
Member since 4/10 7179 total posts
Name:
Katherine
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Help, and I hate Aetna - External Appeal with NYS
I appealed to the state for a procedure for my DD...it was extremely minor compared to your son’s injury and we were reimbursed fully.
Can the doctor that treated him (or anyone that you subsequently followed up with) write a letter on your behalf that it WAS medically necessary? And that he could have sustained further injury had he not been treated?
The whole back-and-forth probably took six months total but in the end we were totally reimbursed.
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| Posted 5/9/18 3:55 PM |
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queensgal
Smile
Member since 4/09 3287 total posts
Name:
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Re: Help, and I hate Aetna - External Appeal with NYS
Have you tried talking to your hr dept?
If they are self-insured, they can force insurance to cover it.
Sorry, this sounds insane
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| Posted 5/9/18 7:20 PM |
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jj8182
LIF Adolescent
Member since 9/10 594 total posts
Name:
J
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Re: Help, and I hate Aetna - External Appeal with NYS
Your insurance denied it and now the hospital is billing you?
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| Posted 5/9/18 10:09 PM |
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LSP2005
Bunny kisses are so cute!
Member since 5/05 19453 total posts
Name:
L
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Re: Help, and I hate Aetna - External Appeal with NYS
Call the NY Attorney General and ask to speak with the healthcare division. They have a helpline for cases. I would also call your HR, and file any and all appeals. You might need an attorney.https://ag.ny.gov/bureau/health-care-bureau
Message edited 5/10/2018 1:32:07 AM.
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| Posted 5/10/18 1:29 AM |
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NYCGirl80
I love my kiddies!
Member since 5/11 10413 total posts
Name:
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Re: Help, and I hate Aetna - External Appeal with NYS
Posted by LSP2005
Call the NY Attorney General and ask to speak with the healthcare division. They have a helpline for cases. I would also call your HR, and file any and all appeals. You might need an attorney.https://ag.ny.gov/bureau/health-care-bureau
This. But first -
What was the denial reason?
Sometimes it's just a missing code. Often, even if it's denied, it's the hospital's responsibility, not yours. My mom had an ER/hospital stay denied because she didn't have pre-approval, but since she went through the ER first, it was the hospital's responsibility to get the pre-approval, not hers. It took about a year, but it got resolved.
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| Posted 5/10/18 9:26 AM |
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JennP
LIF Adult
Member since 10/06 3986 total posts
Name:
Jenn
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Re: Help, and I hate Aetna - External Appeal with NYS
Posted by NYCGirl80
Posted by LSP2005
Call the NY Attorney General and ask to speak with the healthcare division. They have a helpline for cases. I would also call your HR, and file any and all appeals. You might need an attorney.https://ag.ny.gov/bureau/health-care-bureau
This. But first -
What was the denial reason?
Sometimes it's just a missing code. Often, even if it's denied, it's the hospital's responsibility, not yours. My mom had an ER/hospital stay denied because she didn't have pre-approval, but since she went through the ER first, it was the hospital's responsibility to get the pre-approval, not hers. It took about a year, but it got resolved.
They're saying it was not medically necessary.
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| Posted 5/10/18 10:15 AM |
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JennP
LIF Adult
Member since 10/06 3986 total posts
Name:
Jenn
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Re: Help, and I hate Aetna - External Appeal with NYS
Posted by jj8182
Your insurance denied it and now the hospital is billing you?
They haven't actually billed me yet, but yes that's supposed to happen.
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| Posted 5/10/18 10:16 AM |
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JennP
LIF Adult
Member since 10/06 3986 total posts
Name:
Jenn
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Re: Help, and I hate Aetna - External Appeal with NYS
Posted by queensgal
Have you tried talking to your hr dept?
If they are self-insured, they can force insurance to cover it.
Sorry, this sounds insane
DH's company has some type of health advocate and he finally contacted them. Thanks.
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| Posted 5/10/18 10:17 AM |
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NYCGirl80
I love my kiddies!
Member since 5/11 10413 total posts
Name:
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Re: Help, and I hate Aetna - External Appeal with NYS
Posted by NYCGirl80
Posted by LSP2005
Call the NY Attorney General and ask to speak with the healthcare division. They have a helpline for cases. I would also call your HR, and file any and all appeals. You might need an attorney.https://ag.ny.gov/bureau/health-care-bureau
This. But first -
What was the denial reason?
Sometimes it's just a missing code. Often, even if it's denied, it's the hospital's responsibility, not yours. My mom had an ER/hospital stay denied because she didn't have pre-approval, but since she went through the ER first, it was the hospital's responsibility to get the pre-approval, not hers. It took about a year, but it got resolved.
That sounds like a first level denial. The hospital should resubmit it with more information. There are typically 3 rounds of appeals you would have. I know you said you are putting the info together, but in all likelihood, this is something the hospital will handle. Call them first.
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| Posted 5/10/18 10:27 AM |
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