Insurance Complaint

This is the only way I could figure out how to post this. This is a copy of the letter I sent to BCBS of Texas. The letter of medical necessity came from the www.neocate.com website. My best advice is to DOCUMENT DOCUMENT DOCUMENT!! I went back over my cell phone bills and made sure I didn't miss a call.

Here is a link to TX House Bill 2000. I had a copy that was signed but I can't find where on the web I got it :(( www.legis.state.tx.us/tlodocs/81R/analysis/html/HB02000E.htm

The TX Department of Insurance complaint page: http://www.tdi.state.tx.us/consumer/complfrm.html

Texas Attorney General: http://www.oag.state.tx.us/consumer/complain.shtml

June 15, 2010

Blue Cross Blue Shield of Texas

Appeal for Claim # 015515609740C

CC: Texas Department of Insurance Consumer Protection Division

Texas Attorney General Greg Abbott

My son, Gunner, requires Neocate elemental amino acid based formula for his gastroesophageal reflux disease and multiple food protein allergies. I have been requesting that insurance cover the costs of his formula in accordance with House Bill no. 2000 since February 5, 2010. I have been given the runaround by BCBS for over 4 months with the unacceptable final result of $11.34 paid on a claim of over $1300. I am providing details of every phone call I have made and the responses that I have received and feel BCBS is in violation of HB 2000. I am also sending this to the Texas Department of Insurance and the TX Attorney General’s office. I feel that BCBS should be aware of state law affecting their policies and that a customer should not have to fight and waste hours of their own time to receive a benefit of their policy.

January 27, 2010 - Initial call to BCBSTX to request information on how to receive benefits. Was told to fax a letter from his Dr and information to benefits predetermination department

February 5, 2010 - Request and Letter of Medical Necessity from GI Dr faxed to BCBS

February 16, 2010 - 2:56 pm called to confirm receipt

March 5, 2010 - Received a letter stating that “CPT code B4161 enteral formula is not corporately covered by BCBSTX per our Medical Policy guidelines”

March 8, 2010 - 2:05 pm Called BCBSTX computers were down

March 9, 2010 - 4:21 pm Called BCBSTX called to inform them of HB 2000

March 12, 2010 - 8:46 am Called BCBSTX claim sent for review. Assured they would call when it was processed within 2 weeks. Apologized for the mix up saying a number was entered in incorrectly

April 6, 2010 - Received letter from BCBSTX of amendment regarding the addition of amino-acid based elemental formulas to the definition of medical-surgical expense

April 29, 2010 - I had to call to check status of claim. Asked how to do it and told to go to pharmacy and order it like a regular prescription

April 30, 2010 - Called Walgreen’s in Burleson TX (in network pharmacy) to do a test and see if it would be covered. They stated that it was not going though as a covered expense and that I needed to call my insurance company.

May 4, 2010 - 1:10 pm Called BCBSTX to ask what I needed to do and was told to send in a claim form and receipt. She said I could not just get it from the pharmacy like a prescription. I told the service representative that I was buying it online and how that would work. She told me just to send a copy of the bill that was emailed confirming my purchase with his name, the product, date and purchase amount

May 4, 2010 - 2:54 pm called BCBSTX to verify I was sending the correct claim form (Prescription Drug Claim form) and was told it was correct.

May 4, 2010 - Faxed claim forms with CPT code to BCBSTX

May 6, 2010 - Called to confirm fax receipt - receipt confirmed

May 17, 2010 - Received letter from BCBSTX that claim could not be processed because it did not contain correct CPT code

May 20, 2010 - Called BCBS and explained that CPT code was on fax cover sheet and had been provided previously also. Claim sent for review again. Service representative assured she would call me back within 2 weeks when claim was processed.

June 4, 2010 - 11:25 pm I had to call BCBSTX to check status of review. Told it was still in review, but it would be expedited and someone would call me when it was done

June 10, 2010 - 9:49 am I BCBSTX again to check the status of the review. Was told it was still in review until I told the service representative to note in the account that I was reporting this to the Attorney General, then after a few minutes on hold I was told a check for $11.34 had been sent out on 6/9/10. The operator had stated that since I was purchasing out of network, they didn’t have to cover the expenses.

My complaint is that:

1. I should have never been told it wasn’t covered per Medical Policy guidelines
2. I called an in-network pharmacy who tried to send through a test claim and it was denied
3. When I said I was buying it online, the service representative should have mentioned it should be coming from an in-network provider
4. I was never called back when I was assured several times I would be. I shouldn’t have to keep calling to make sure someone’s job gets done
5. I can not afford to pay and extra $100 per 2 cases with no assurance that I will be reimbursed by insurance who has continually refused to acknowledge coverage.

Purchasing directly from Neocate - Nutricia North America I am getting 2 cases (8 cans) for $242.25. If I purchased from Walgreen’s out of pocket, the cost would be $352.

I am requesting that I be reimbursed the full amount of $1352.06 and for all Neocate purchases from Nutricia North America through June 15, 2010 for the time and effort it has required to get cooperation from BCBSTX. I would also request timely and accurate information and processing on future claims regarding Neocate infant formula.

However, I would like to commend all the service representatives that I spoke with. Even though most of them gave me inaccurate information and didn’t return calls, they were very friendly and courteous even when I was extremely frustrated with the situation.

I am attaching copies of documents referred to above:

Copy of my insurance card with Gunner’s name and dob

Letter of Medical Necessity from Pediatric Gastroenterologist

Copy of House Bill 2000

Letter from BCBSTX dated March 5, 2010

Letter from BCBSTX dated April, 6, 2010

12 page copy of claim sent to BCBS on May 4, 2010

Letter from BCBSTX dated May 17, 2010

Explanation of Benefits dated June 9, 2010

Thank you for your consideration

Kara Shipman