Complaint Review: Blue Shield Of CA - Chico California

That letter above is not going to do anything. I work for a insurance company not bsbc but know what they have to follow. First off the federal mandate states if a member can prove they had coverage 18 months prior then they have to wave all pre-x. Most insurance plans offered by employers do not have to follow local and state laws. Only laws writtin for "self funded" plans. To get around this pre-x issue is simple get fill out the forms they send you and send back. They will also send the samething to the doctor's the claims are for and any doctor that you put on the paper work. At that point they can review to see if you were treated for it. Most of the time they will pay the claim. Threating with a laywer does nothing 90% of the time. Almost all the rules in insurance now is federal law not the insurance company. That is one of the reasons they will not send medical records to you. Per Hippa if they can not 100% prove who you are they can not give out that information. Most of the time they will only give out that info with a court order and then its not what you think. Most of the info they have on you is just bills that say nothing.

Finally after we had to hire a lawyer Blue Shield did pay. They are however not providing us copies of all documents that we requested. I sent a letter requesting all documents pertinent to the claims and they sent a letter back stating it is confidential information between the doctor and them, stated some HIPA law. If we want copies of any claims we have to get it from the doctor. I think that is crap since the letters are from my husband and he is the patient so HIPA would not apply in this case. I don't care at this point. The bills are paid and that is what I wanted.

Send them this letter. In 30 days, file a greivance with the California Department of Managed Health Care. If they have not provided the records, then use that as another basis for your complaint. If they send you the records, send those records as part of your complaint. Request for Records To: [HMO or insurer] From: [Member] Member Number: Date: Ref: Your Denial Letter of [date] Under ERISA, (29 USC 1132(c)(1)(B) and 29 CFR 2560.503-1(g)(1)(ii)) I have a right to copies of pertinent documents that [HMO or insurer] relied on in making its decision to deny my [type of claim] benefits. I am hereby formally requesting copies of all such records used or referred to by, or influencing you in making that decision, including: * All medical records and reports of diagnostic tests, * All medical literature and guidelines consulted, * All related correspondence and internal e-mail, * All records of phone calls, * Communications between [HMO or insurer], myself and any other party, * All information from third-party sources, such as consultants, MIB or investigative reports, and * Any other documented information that may have influenced your decision to deny my claim in this matter. Please note that the ERISA sections cited authorize fines of up to $110 per day if the requested documents are not delivered within 30 days after the date of this request. I shall rely upon the completeness of your response, and shall resist the production at a later date of any records predating your last denial letter which are not produced in response to this request. Thank you for your assistance. __________________ (signed) MAKE SURE THIS LETTER IS SENT CERTIFIED WITH A SIGNED RETURN RECEIPT!! The letter clearly states that only the documents they send will be valid to their denial so they can't continue on their fishing expedition to find anything that they can remotely relate to the medical condition. For example, if your husband ever seen a doctor about a different mark or even rash or anything in the vicinity of the current cancer location, they will use that as proof even if it was 20 years ago. Don't give them time to find some erroneous excuse, they have been known to go as far back as childhood. Here is the info for the California DMHC. Department of Managed Health Care HMO Help Center Call 1-888-HMO-2219 (1-888-466-2219) TDD: 1-877-688-9891 There is no charge for your call. The HMO Help Center is open 24 hours a day, 7 days a week.

Most preexisting condition clauses also state that even if the condition was not treated by a doctor, if it is a condition for which a prudent person would have sought treatment, the condition will still be considered to be preexisting. Lets take an extreme example. You are coughing up blood. You don't go to the doctors, instead going to an insurance agent. You buy health insurance. If the company knows that you were coughing up blood whether or not you went to the doctor doesn't matter. A prudent person would seek treatment.

I am not connected with BS of CA in any way. I have been a medical insurance biller for over 25 years and I think I can help. Because this consumer's claim was so close to the effective date of the coverage, it is understandable that BS is questioning the validity. To determine if this diagnosis was "pre-existing" under the terms of the coverage, Blue Shield wants to see records from the patient's doctors prior to the time of diagnosis. If the consumer did not see a doctor EVER prior to this illness, that would be hard to believe. To prove it may be an uphill battle, but in the end it is BS who must prove the condition did exist in the 6 months (for California) previous to the effective date of coverage. If this is the case possibly BS would accept a sworn statement before a notary that there are no medical records to be sent. If the patient did see a doctor (any doctor), the records of those visits need to be sent directly from the doctor's office to BS. If the consumer obtains the records and forward them himself, BS may not accept them.