ࡱ> QSPM S*bjbj== )VWWS&lx x x x "~"""""""$# %"""B~"~"& ** by x ^**T"0"*& &* Request for Out of Area Coverage or Denial of Coverage Request for Disenrollment from Insurance planSituation. I have Prostate Cancer and want to have Proton Beam Therepy at the Loma Linda Institute in California. Although this procedure is done in Massachusetts, I have been told that Loma Linda does 150 of these procedures each day while the hospital(s) in Massachusetts only do 1 or 2 each day. Loma Linda has been doing these procedures for longer than the hospitals in Massachusetts. I have been told that there are only 4 hospitals in the U.S. that do this procedure. I have been accepted for treatment at Loma Linda and have to get the Insurance matters settled so that Loma Linda can be assured of getting paid.11 or 12/ /07Julie 909-5584000 X88635 - from Loma Linda called an asked me about my Health Insurance plans. I told her that my primary Insurance was from my employer(the Woods Hole, Marthas Vineyard and Nantucket Steamship Authority (SSA)). My primary insurance was from New England Benefit Trust and that I also had Medicare and Tricare for Life from my military service.11 or 12/ /07Loma Linda reports that, although I have 3 Insurances. (Primary- New England Benefit Trust, Medicare and Tricare for Life), my primary insurance will not pay for the procedure because Loma Linda is out of the coverage area. They do know that my two secondary insurances will cover the cost of the procedure. They believe that if they go ahead and do the procedure and then bill the primary carrier, New England Benefit Trust, and then get denied by the primary carrier, the secondary carriers will refuse to pay because I have a primary insurance carrier who does cover the procedure in the primary carriers area. (I suspect that they wont go ahead and do the procedure if they are not reasonably sure that they are going to get paid in a timely manner and without a lot of back and forth arguing about whos going to pay.) Loma Linda suggests that I get an Out of Service Area coverage Letter or a Denial of Service letter from New England Benefit Trust. We also discussed dropping my New England Benefit Trust insurance so that Medicare and Tricare would pick up the bill.12/ /07All employees received a letter and contract from my employer, the WH,MV,& N, Steamship Authority (SSA), that my Health Insurance would have to be renewed by signing a renewal document by Jan 1, 2008. If the document was not signed by Jan 1st, coverage would be suspended. Further, that if an election was made to renew coverage, the coverage could not be terminated by the Insured for the rest of the year. Thisletter/contract was the result of a change in plan from ? to a cafeteria atyle plan. Very little information was given with the contract. I decided to delay my decision to renew or not renew until I had more information. 12/ /07Went to Primary Care Physician, Dr. Kendall, MV Hospital, with a Request for Coverage at Loma Linda or a Denial of Coverage from New England Benefit Trust12/ /07I called Blue Cross and explained that I wanted to go to Loma Linda in California, and that I was seeking a Denial of Coverage so that I could get my other insurance plans to pick up the cost of the procedure and that if I could not get a Denial that I could drop the Insurance at any time prior to Dec 31. 2007. At that time, I was assured by the Blue Cross representative that Blue Cross would most likely deny the coverage and that I wouldnt have to drop my Insurance and that regardless of my decision to drop or keep my insurance, my Blue Cross Insurance would have to stay in effect until March 31st because it had already been paid for . On the Basis of this advice that Blue Cross would likely deny coverage at Loma Linda and that that would clear the way for my other Insurance plans to pay for the procedure and also the fact that my insurance coverage could not be suspended until April 1, 2008, I renewed my Insurance with New England Benefit Trust on Dec 31,2007 approx.01/ /07Dr Kendalls secretary reports that letter has been sent to New England Benefit Trust01/26/08 approx.Received a letter from Blue Cross, which disapproved the coverage of the service because I did not meet the medical necessity criteria required for a visit with a non-participating specialist. Coverage was denied because the situation was not an emergency as defined in the Subscriber Certificate, the same service was/is available in-network, and I am medically able to travel back to the service area.01/26/08 approxLetter was faxed to Julie at Loma Linda to see if it satisfied their criteria for Denial of Coverage.01/27/08 approx.Julie reports that Loma Linda cannot accept this letter as a Denial of Coverage. They suggest that I could request a Letter of Disenrollment.01/ /07I requested disenrollment from Insurance from my employer, the WH,MV,& N, Steamship Authority (SSA) and was told by Bob Young, Comptroller, that because I signed the renewal form, disenrollment was not possible01/ /08Saw Phil Parent, Human Resources-SSA) and explained situation regarding the inability to get the Cancer procedure done at Loma Linda under the company Insurance plan and the inability to disenroll from the company insurance plan. He referred me to Dave Cabral, Teamsters01/ /08Dave Cabral sent issue to Edwinna @ Teamsters02/01/08Edwinna called me, I explained situation, and asked for help to either get a Denial of Coverage or a termination of Health Insurance. Edwinna will call Blue Cross. 02/01/08Edwinna reports that Blue Cross will not cancel Health Insurance. In regards to the Denial of Coverage issue, Blue Cross says that I must get a note from Loma Linda requesting Out of Area Coverage or a Denial of Coverage. Edwinna will call Loma Linda and request a letter requesting out of Area Coverage or Denial of service02/01/08Blue Cross will not cancel Health Insurance02/ /08Julie at Loma Linda reports that she called Blue Cross and spoke to Richard, who said that he would not give a Denial of Coverage and that he would not discuss this matter any more.02/25/08Spoke to Bob Young, Comptroller, SSA about having the insurance cancelled for lack of Payment by me. Bob said that that was not possible. He referred me to Brenda Albin, New England Benefit Trust-Teamsters Behavioral Health 1-800-258-9732 X225 in regards to dropping the Insurance.02/26/08Called Brenda Albin, New England Benefit Trust, on the advice of Bob Young, Comptroller, SSA. I explained to Brenda that I had Prostate Cancer and that I wanted to go to Loma Linda Institute in California for Proton Beam Therapy. I explained that I worked for the SSA and that I had 3 insurance plans. My primary insurance was from New England Benefit Trust and that I also had Medicare and Tricare for Life from my military service. I had tried to get a Denial of Coveragge from Blue Cross and that they would not give me a Denail of Coverage. I explained that I could get Medicare and Tricare for Life to cover the cost of the treatment but that Loma Linda would not do the procedure without the assurance that they would get pid. I explained that Loma Linda believes that if they go ahead and do the procedure and then bill the primary carrier, New England Benefit Trust, and then get denied by the primary carrier, the secondary carriers will refuse to pay because I have a primary insurance carrier who does cover the procedure in the primary carriers area. They wont go ahead and do the procedure if they are not reasonably sure that they are going to get paid. I explained that I had a letter from Blue Cross that stated that they would not approve the Out of State Coverage and that they would not deny coverage because the procedure is available in the coverage area. I explained that Loma Linda would not accept this letter as a Denial of Coverage. Brenda explained to me that the normal procedure is for Loma Linda to do the procedure and try to collect from the primary insurer, who would deny the claim and then Loma Linda would collect from the secondary insurers. I also asked about dropping my insurance and she said that because I signed the document that I could not drop the insurance. I asked her if I quit my job, how long must I wait to be disenrolled. She said that the New England Benefit Trust insurance would remain in force until June 31, 2008. My conclusion is that even if I quit my job , it would still be July before I could get my cancer treatment at Loma Linda Institute. Brenda said that she would call Blue Cross and request the documents and offered to call Loma Linda for me. I said I would call her back with the contact information at Loma Linda.02/26/08Called Brenda Albin, New England Benefit Trust-Teamsters Behavioral Health in regards to dropping the Insurance and getting the Denial of Coverage. Brenda told me that because I signed the document that I could not drop the Insurance02/26/08I left the contact information on Brendas Answering machine.02/27/08Brenda called and told me that she had talked to Blue Cross and that they would not Deny the claim prior to the procedure being performed. Brenda said that she had talked to Julie at Loma Linda and Julie said that they want a denial prior to the procedure. Brenda told me that she had her representative working to see if there was a way around this impasse02/27/08I asked Brenda where the rule came from that I could not drop my insurance. She told me that the SSA had given me a document that I signed. I then asked where does the rule come from. She told me tht it was the new Massachusetts law that required all employees to have Health Insurance. 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