According to the San Francisco Chronicle, as of 2023, about 15.3 million people—almost 40 percent of the state’s population—are enrolled in Medi-Cal. That number increased by almost three million during the pandemic. Anthem Blue Cross Medi-Cal managed care denial can be devastating for you and your family members. After all, a procedure, test, medical device, or prescription drug that your doctor believes will help your illness or injury that has been denied may leave you wondering where to turn next. Attorney Scott Glovsky can be the advocate in your corner that you desperately need during this difficult time. Scott fights every day for justice, and he will fight for you with the same passion.
What Are Medi-Cal Plans?
With one in three Californians getting their health insurance through Medi-Cal, the program is essential to low-income and no-income families. About 80 percent of all Medi-Cal recipients fall under a managed care plan, while the remainder of Medi-Cal recipients use a fee-for-service system to access care. Medi-Cal programs are administered at the local level by County human services departments. While some counties will administer only one plan—meaning all members in the county will be enrolled in that plan—most counties offer a variety of commercial plans, including Molina, Blue Shield of California Promise Health Plan, Health Net, Kaiser Permanente, and Anthem Blue Cross.
You must meet the income requirements or be eligible because of your health status or age to apply for Medi-Cal. You can apply online, in person, or by mail, and will be asked for SS numbers for all family members, the employment status of all working adults in our household, federal tax information, and whether you have health insurance through your employer. Medi-Cal provides a range of health benefits, including “essential health benefits” required by the Affordable Care Act. These benefits include:
- Preventative and wellness services
- Chronic disease management
- Hospitalization
- Emergency services
- Outpatient services
- Maternity care
- Newborn care
- Mental health treatment
- Prescription drugs and laboratory services
- Physical and occupational therapies
- Children’s services, including vision and dental
Anthem Blue Cross Insurance Provider and Its Medi-Cal Plans
Anthem Blue Cross Medi-Cal services Medi-Cal residents in Alpine, Amador, Calaveras, El Dorado, Fresno, Inyo, Kern, Kings, Los Angeles, Madera, Mono, Sacramento, San Francisco, Santa Clara, Tulare, and Tuolumne counties. All are direct with Medi-Cal except Los Angeles where Anthem partners with L.A. Care Health Plan. In other words, people with L.A. Care have the option of selecting Promise Health Plan or Anthem Blue Cross providers. When you are an Anthem Blue Cross Medi-Cal member, you will receive free or low-cost healthcare services, including:
- Hospitalization
- Doctor visits
- Vision care
- Specialist referrals
- Prescription drug and laboratory services
- Dental care
- Transportation services
- Medi-Cal for Kids and Teens
- Care management programs
- Long-term services and support
- Healthy Rewards
Do Anthem Blue Cross Managed Care Plans Work with Independent Physician Associations (IPA)?
Anthem Blue Cross Medi-Cal Managed Care health plans work with IPAs. Independent Practice/Physician/Provider Associations are independent medical groups with their own health care practices. Some IPAs include imaging centers, Urgent Care, hospitals, and more. What is significant about relationships with IPAs is that they typically approve and deny medical care in these relationships. Some of the IPAs that work with Blue Cross include Preferred IPA of California and Regal Medical Group. Discover more about the insurer/IPA relationship here.
What Types of Services Might Anthem Blue Cross Deny?
An Anthem Blue Cross Medi-Cal managed care denial can cause despair when the treatment prescribed by your doctor is denied. While any health insurer can—and will—issue denials for a variety of reasons, some insurers issue more denials than others. You may have received a denial because your paperwork was not properly filled out, or information was missing. You may not have obtained prior authorization for a treatment, or the treatment may be specifically denied in your Anthem Blue Cross policy. Unfortunately, in other cases, an insurance company may use denials that include the terms “experimental,” “investigational,” or “not medically necessary,” to mask the fact that they don’t want to pay for an expensive treatment.
Recent advances in cancer treatments can potentially help cancer victims live longer, healthier lives, yet you may have received an Anthem Blue Cross Medi-Cal managed care denial for such a procedure. The bottom line could be that Anthem Blue Cross simply does not want to pay for the prescription drug, treatment, or test. Fortunately, you do have options after receiving an Anthem Blue Cross Medi-Cal managed care denial. There are appeals that you and your attorney can file, and other steps that can be taken as well, so don’t lose hope following Anthem Medi-Cal denials.
What Steps Should You Take if Anthem Blue Cross Denies Your Medi-Cal Claim?
If you’ve received an Anthem Blue Cross Medi-Cal managed care denial and want to have the denial reversed, there is a process in place that will allow you to file an internal appeal—and an external appeal if necessary. Anthem’s Medi-Cal Member Handbook explains the appeals process It is slightly different than the appeals process for employer healthcare or individual and family healthcare purchased from the Affordable Care Act marketplace,
The Notice of Action (NOA) letter you received from Anthem Blue Cross should give you the reason or reasons for its denial. If you have not received this letter, you must contact Anthem to find out why your claim was denied. It is always a good idea to ask for the criteria for coverage of this medical treatment so you understand in what situations Anthem will approve this care. An internal appeal is the first step you will take, and you have 60 days to do so from the date of the NOA letter. There are multiple ways to file your appeal – via telephone, via mail, or even online. You will ask your insurer to take another look at your claim and reconsider its decision. A simple error or incomplete information can be fixed, and the denial reversed. A denial that says the treatment is not medically necessary or is investigational or experimental, requires that you first file an internal appeal.
Anthem has 30 days to decide your appeal if it is for a treatment you have not already received. If you are appealing a denial for a treatment you have already received, Anthem must reply within 60 days. If your medical issue is urgent, Anthem only has 72 hours to make a decision. Anthem’s determination of your appeal is called a Notice of Appeal Resolution (NAR). If Anthem doesn’t respond within 30 days, then its determination is considered to be another denial.
When Anthem denies your appeal, you have a few options. You can ask for a State Hearing from the California Department of Social Services (CDSS) and you can request an Independent Medical review (IMR) from the Department of Managed Healthcare (DMHC). In the case of the IMR, a neutral third party will fully review your denial a make a decision that is binding on Anthem. You have the right to both a hearing and an IMR, however, if the state hearing has already occurred, then you may not ask for an IMR and the decision of the hearing will stand.
How the Law Offices of Scott Glovsky Can Help With An Anthem Blue Cross Medi-Cal Managed Care Denial
After receiving Anthem Medi-Cal denials, many people will simply give up on a treatment they need for their health. You don’t need to give up—attorney Scott Glovsky fights for justice on behalf of his clients every day—going up against big insurance companies and never backing down. While many attorneys make a point of not getting personally involved with their clients, this leaves those clients feeling lost and uncared for. Scott and his team believe you deserve highly individualized, highly personalized service as we fight for your rights and your future. Contact the Law Offices of Scott Glovsky today.