Health Insurance Grievance Procedures

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Affordable Health Care Act
Blue Cross Summary 6/2011
Blue Cross Anthem Summary 10/22/2010
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45 CFR Part 147 Interim Final Rules for Group Health Plans and Health Insurance Issuers 

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Before calling DMHC it is best to go through your Insurance Companies Grievance Procedures

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Claim Denial
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Getting Employer Group coverage issue under AB 1672
Balance Billing Problem
Improper Pre-X denial on HIPAA, after COBRA

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We would charge a non client maybe $150 to draft something like this.  Please note we are NOT attorneys and cannot give legal advise or represent you in court.

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Here's research where a client applied for HIPAA on the 45th day and did NOT choose the option to get HIPAA if the underwritten plan did not go through.  We did not finish the project... as the reason for denial was minor and we are confident another company would write the coverage standard or with a surcharge, but less than HIPAA rates.  Check out our Pre Application Forms.

Medical Necessity

Reasons why the Claim might be denied

Did you tell the truth on your application?
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Here's where they write to your MD, before a claim is even turned in.

You may also be eligible for an Independent Medical Review (IMR)

Was the procedure you had Medically  Necessary?

Arthur Shorr (no relation) on hospital billing

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Insurer's Bad Faith

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005 Update - from the Kaiser Foundation  


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Fines against PacifiCare for improper claims handling 1/30/2008 CHFC

Health Net faces suit over refusal to cover treatments LA Times 9.13.2012

Insurance Company Grievance Procedures


Blue Cross Grievance Procedures

Blue Shield - General Info.
Appeals & Grievances
PO Box 629007
El Dorado Hills , CA 95762 - 9007

Fax: (916) 350 - 7585

Start Here Mental Health Parity Misstatements Universal Care Worker's Comp. Dictionary FAQ's Grievance Cancer, Hospital Indemnity Legislative History Purchase - Consulting Late Enrollee Pac Advantage Resources
Medical Necessity

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7/26/2011 Final Rules EBSA Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction [PDF]

More Final Rules for EBSA

10123.13. (a) Every insurer...shall reimburse claims ..., whether in state or out of state, ... as soon as practical, but no later than 30 working days after receipt...

(b) If an uncontested claim is not reimbursed ... within 30 working days...interest shall accrue and shall be payable at the rate of 10 percent per annum ...

Search & Find CPT Current Procedural Terminology codes and their relative values at CPT Code/Value Search - Medicare Billing Codes This is a free site for patients and consumers.

See also Medical Necessity

California Insurance Code  790.03 (h) Knowingly committing or performing with such frequency as to indicate a general business practice any of the following unfair claims settlement practices:   Calif. Code of Regulations TITLE 10. CHAPTER 5 ADOPT SUBCHAPTER 7.5 with new 2004 amendments on CA Department of Insurance Site
   (1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any coverage's at issue.
   (2) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies.
   (3) Failing to adopt and implement reasonable standards for the prompt investigation and processing of claims arising under insurance policies.
   (4) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been completed and submitted by the insured.  

(5) Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear.
   (6) Compelling insured's to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by the insured's, when the insured's have made claims for amounts reasonably similar to the amounts ultimately recovered.
   (7) Attempting to settle a claim by an insured for less than the amount to which a reasonable person would have believed he or she was entitled by reference to written or printed advertising material accompanying or made part of an application.
   (8) Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured, his or her representative, agent, or broker.
   (9) Failing, after payment of a claim, to inform insured's or beneficiaries, upon request by them, of the coverage under which payment has been made.
   (10) Making known to insured's or claimants a practice of the insurer of appealing from arbitration awards in favor of insured's or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration.
   (11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either, to submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information.
   (12) Failing to settle claims promptly, where liability has become apparent, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
   (13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance policy, in relation to the facts or applicable law, for the denial of a claim or for the offer of a compromise settlement.
   (14) Directly advising a claimant not to obtain the services of an attorney.
   (15) Misleading a claimant as to the applicable statute of limitations.
   (16) Delaying the payment or provision of hospital, medical, or surgical benefits for services provided with respect to acquired immune deficiency syndrome or AIDS-related complex for more than 60 days after the insurer has received a claim for those benefits, where the delay in claim payment is for the purpose of investigating whether the condition preexisted the coverage. However, this 60-day period shall not include any time during which the insurer is awaiting a response for relevant medical information from a health care provider.
   (i) Canceling or refusing to renew a policy in violation of Section 676.10.

Medical Necessity


Date: Fri, 30 Jul 2010
Subject: Re: HIPAA - No Pre X

Hi Steve,

We can't thank you enough for your help with this. But we'll try anyway:

Thank you Thank you Thank you Thank you Thank you Thank you Thank you Thank you

Bob K & Jude S

On 7/30/2010 4:04 AM, Individual HIPAA Support wrote:

I have looked into this issue of Pre X. This seems to be a system issue not an enrollment issue. When the enrollment was done I placed an indicator in they system to indicate that pre x is covered. The system after the enrollment was done changed the indicator. I have corrected the issue and will be sending a request to the claims area to have claims reprocessed correctly.
Also I see you asked about the practice of age when enrolling. The oldest applicant is the subscriber. So if the applicant is 63 and the spouse is 64. The spouse is the main subscriber and the rates for the oldest spouse is what should be quoted.

*From:* Steve Shorr Insurance []
*Sent:* Thursday, July 29, 2010 6:04 PM
*To:* Robert K

*Subject:* HIPAA - No Pre X


Attached is a .pdf package for Mr. K in reference to Aetna's inquiries about the Pre-X clause. As we know, HIPAA is not issued without 18 months of prior coverage, with then negates any pre - x waiting period.

Let me know if you need more exact legal citations.

Please pay Mr. K's claims today. Please review ALL of your HIPAA business and make sure that you are not asking for the same thing of the other insured's.


P.S. What is Aetna's practice on using which age of a spouse?

At 02:33 PM 7/29/2010, you wrote:

Hi Steve,

We just got this EOB from AETNA.

Both remarks at the bottom say the claims are pending review during to the pre-existing condition limitation of our plan.

Of course, we do not have a pre-existing limitation since we got a HIPPA plan and proved at the time we had the required amount of time of coverage.

I am attaching the EOB as a PDF (I believe you had requested PDF files when I send stuff?).

Also attached is a PDF of our Certificate of coverage detailing at least 18 months of coverage up to our end date of 31 January 2010.

If there is anything you can do to get these folks sorted out we would really appreciate the help.

Of course, if there is anything else you want me to try like letters etc, I will give that a shot.

Thanks again for your continuing help.

By the way, Aetna put my wife's name as the primary on the policy. When I asked way back when about this, they said they always put the older person on as the primary. I think it is something about allowing them to increase the rates sooner. Which they are doing in September from our present 1107/month up to 1334/month. What charming folks.

Best regards,

Bob K
J  S